1

 

                 DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

                       FOOD AND DRUG ADMINISTRATION

 

               CENTER FOR FOOD SAFETY AND APPLIED NUTRITION

 

 

 

 

 

 

 

 

 

 

                     FOOD ADVISORY COMMITTEE MEETING

 

Advice on CFSAN'S Draft Report:

Approaches to Establish Thresholds for Major Food Allergens and for Gluten in Food

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                         Thursday, July 14, 2005

 

                          8:30 A.M. to 5:20 P.M.

 

 

 

 

                            Greenbelt Marriott

                              6400 Ivy Lane

                              Grand Ballroom

                        Greenbelt, Maryland 20770

                                                                  2

 

                         P A R T I C I P A N T S

 

       FOOD ADVISORY COMMITTEE STANDING MEMBERS:

 

       Richard A. Durst, Ph.D. - Acting Chairman

       Jeffrey A. Barach, Ph.D. (Industry Representative)

       Patrick S. Callery, Ph.D.

       Dennis Gonsalves, Ph.D., M.S.

       Jean M. Halloran (Consumer Representative)

       Douglas C. Heimburger, M.D., M.S.

       Margaret C. McBride, M.D.

       Mark Nelson, Ph.D. (Industry Representative)

       Carol I. Waslien Ghazaii, Ph.D., R.D.

 

       TEMPORARY VOTING MEMBERS:

 

       Petr Bocek, M.D., Ph.D. (Absent 7/14/05 Session)

       Margaret Briley, Ph.D., R.D.

       Erica Brittain, Ph.D.

       Ciaran P. Kelly, M.D.

       Soheila June Maleki, Ph.D.

       David O. Oryang

       Marc D. Silverstein, M.D.

       Suzanne Teuber, M.D.

 

       FOOD AND DRUG ADMINISTRATION:

       Robert E. Brackett, Ph.D. - Director

       Food and Drug Administration, CFSAN

 

       Catherine Copp, J.D. - Senior Policy Advisor

       Food and Drug Administration, CFSAN

 

       Steven M. Gendel, Ph.D. - Senior Scientist

       Food and Drug Administration

       National Center for Food Safety and Technology

 

       Rhonda Kane, M.S., R.D. - Consumer Officer

       Food and Drug Administration, CFSAN

 

 Marcia Moore, Food Advisory Committee, Executive Secretary

                                                                  3

 

                   P A R T I C I P A N T S (Continued)

 

       FOOD AND DRUG ADMINISTRATION STAFF:

 

       Michael M. Landa, J.D. - Deputy Director for Regulatory Affairs

 Food and Drug Administration, CFSAN

 

 

       Stafano Luccioli, M.D. - Senior Medical Advisor

       Food and Drug Administration, CFSAN

 

       GUEST SPEAKERS:

 

       Pekka Collin, M.D., M.P.H. - Professor

       University of Tampere, Medical School, Finland

 

       Catherine L. Copp, J.D.

       Policy Advisor, CFSAN, FDA

 

       Alessio Fasano, M.D. - Professor of Pediatrics

       Medicine & Physiology and Director, the Mucosal

       Biology Research Center, Center for Celiac

       Research, University of Maryland School of

       Medicine

 

       Steven M. Gendel, Ph.D. - Senior Scientist

       National Center for Food Safety and Technology, FDA

 

       Rhonda R. Kane, M.S., R.D. - Consumer Safety

       Officer CFSAN, FDA

 

       Donald Kasarda, Ph.D. - Consultant and Retired

       Senior Scientist, Agriculture Research Service,

       USDA

 

       Cynthia Kupper, R.D., C.D. - Executive Director

       Gluten Intolerance Group of North America

 

       Joseph A. Murray, M.D. - Professor of Medicine

       The Mayo Clinic of Rochester, Minnesota

                                                                  4

 

                             C O N T E N T S

 

                                                               PAGE

       Call to Order and Welcome and Introductions

                 Richard Durst, Ph.D., Acting Chairman            6

 

       Use of Gluten Thresholds

                 Catherine L. Copp, J.D., CFSAN, FDA              9

 

       Introduction to Celiac Disease

                 Joseph Murray, M.D.                             11

 

       Patient Perspectives on Celiac Disease

                 Cynthia Kupper, R.D., C.D.                      69

 

       Grains

                 Donald Kasarda, Ph.D., USDA                     84

 

       Question and Answer Session                              108

 

       Prospective Studies

                 Alessio Fasano, M.D.                           114

 

       Question and Answer Session                              146

 

       Retrospective Studies

                 Pekka Collin, M.D., M.P.H.                     161

 

       Question and Answer Session                              182

 

       International Perspectives on Gluten-Free

                 Rhonda S. Kane, M.S., R.D., CFSAN, FDA         186

 

       Question and Answer Session                              198

 

       Public Comments:

 

                 Elaine Monarch                                 212

 

                 Alice Bast                                     220

 

                 Mary Schluckabeer                              225

 

                 Tom P. Sullivan                                232

 

                 Steve Taylor                                   240

                                                                  5

 

                             C O N T E N T S

 

                                                               PAGE

 

       Overview of Approaches to Establishing

         Thresholds: Gluten

                 Steven M. Gendel, Ph.D.                        253

 

       Question and Answer Session                              257

 

       Committee Discussion:

 

                 Panel Discussion with Guest Speakers           259

 

                 Gluten and Celiac Disease - FDA Questions      287

 

                 Revisit Food Allergens                         354

 

       Adjournment

                 Richard Durst, Ph.D., Acting Chairman          363

                                                                  6

 

                          P R O C E E D I N G S

 

               CALL TO ORDER AND WELCOME AND INTRODUCTIONS

 

                 CHAIRMAN DURST:  Good morning.  I would

 

       like to call the meeting to order.  All right, I

 

       would like to welcome everyone back and also

 

       welcome new participants in our meeting this

 

       morning.

 

                 For those of you who weren't here

 

       yesterday, there is a "Conflict of Interest

 

       Statement" over on the table, if you want to refer

 

       to that at all, otherwise I would also ask again

 

       that maybe our participants or our members of the

 

       Food Advisory Committee would introduce themselves

 

       again for the benefit of those who were not here

 

       yesterday.

 

                 I am Dick Durst, professor [of]chemistry at

 

       Food Science and Technology Department at Cornell

 

       University.

 

                 Marc, would you start it off?

 

                 DR. SILVERSTEIN:  Marc Silverstein, I'm a

 

       general internist and geriatrician at Baylor Health

 

       Care System in Dallas.

                                                                  7

 

                 DR. TEUBER:  Suzanne Teuber, I am an

 

       allergist at UC-Davis.

 

                 MR. ORYANG:  I am David Oryang.  I am a

 

       risk analyst and agricultural engineer at the

 

       United States Department of Agriculture, Animal and

 

       Plant Health Inspection Service.

 

                 DR. KELLY:  Good morning.  Ciaran Kelly, I

 

       am a gastroenterologist at Harvard Medical School

 

       in Boston.

 

                 DR. MALEKI:  I am Soheila Maleki.  I am a

 

       scientist with the USDA.

 

                 DR. BRITTAIN:  Erica Brittain, I am a

 

       statistician at the National Institute of Allergy

 

       and Infectious Disease.

 

                 DR. BRILEY:  Margaret Briley, University

 

       of Texas at Austin, nutritionist.

 

                 MRS. MOORE:  Marcia Moore, I am the

 

       executive secretary for the Food Advisory Committee

 

       and the Food and Drug Administration.

 

                 DR. WASLIEN:  I am Carol Waslien,

 

       nutritional epidemiologist at the School of

 

       Medicine, the University of Hawaii.

                                                                  8

 

                 DR. BRILEY:  I am Margaret McBride, child

 

       neurologist at Akron Children's Hospital.

 

                 DR. CALLERY:  Pat Callery, West Virginia

 

       University, pharmaceutical scientist.

 

                 DR. GONSALVES:  I am Dennis Gonsalves, a

 

       scientist at USDA.

 

                 DR. HEIMBURGER:  I am Doug Heimburger, a

 

       physician and nutrition specialist at the

 

       University of Alabama at Birmingham.

 

                 DR. BARACH:  Jeff Barach with Food

 

       Products Association here, in Washington, D.C., in

 

       regulatory affairs.

 

                 DR. NELSON:  Mark Nelson with the Grocery

 

       Manufacturers Association here, in Washington,

 

       D.C., and I am responsible for scientific and

 

       regulatory policy.

 

                 MS. HALLORAN:  Jean Halloran with

 

       Consumers Union located in Yonkers, New York, and I

 

       am director of food policy initiatives.

 

                 CHAIRMAN DURST:  Thank you very much.

 

                 I would also like to remind everyone and

 

       also for our new people here at the meeting that

                                                                  9

 

       the "Charge" of the Committee is written out on the

 

       meeting document.  The most important thing is that

 

       we are focusing on the "Threshold Working Group

 

       Draft Report on Approaches to Establish Thresholds

 

       for Major Food Allergens and for Gluten in Food."

 

                 We are not here to set any kind of

 

       thresholds or discuss the labeling of these foods

 

       for allergens, but strictly to make comments on the

 

       best approaches to use for setting these

 

       thresholds.

 

                 Did I cover everything that we need to?

 

                 (No verbal response.)

 

                 CHAIRMAN DURST:  In that case, let's begin

 

       with our first presentation.  This is

 

       Catherine Copp, the policy advisor for CFSAN, FDA,

 

       on the use of gluten thresholds.

 

                         USE OF GLUTEN THRESHOLDS

 

                 MS. COPP:  I have been asked this morning

 

       to proceed with discussion on gluten and threshold

 

       levels for gluten or possible thresholds for gluten

 

       framework.  It is similar to yesterday.  I simply

 

       want to provide you with some context for the

                                                                 10

 

       evaluating the Draft Report portion that addresses

 

       gluten in food.  This is the hazard of being first.

 

                 (Slide.)

 

                 MS. COPP:  Yesterday, I mentioned the Food

 

       Allergen Labeling and Consumer Protection Act.

 

       This is a new law that Congress passed last August.

 

       Although it focuses primarily on allergens, food

 

       allergens, Congress also directed FDA to address

 

       the separate problem of gluten in food.

 

                 When I say directed, I mean that Congress

 

       has mandated that the Agency consider and then

 

       establish regulations according to a schedule to

 

       define "gluten-free" for use on food labels and

 

       also to identify the appropriate use of the term.

 

                 As with Allergens, for consumers with

 

       celiac disease, strict avoidance of gluten at

 

       levels that will elicit an adverse effect is the

 

       only means to prevent potentially serious

 

       reactions.

 

                 Accurate, complete and informative

 

       labeling on foods can help these consumers achieve

 

       their goal.  We believe that understanding

                                                                 11

 

       thresholds for gluten and having a sound scientific

 

       framework for evaluating the existence of such

 

       thresholds will help FDA develop a definition of

 

       gluten-free and identify appropriate use of the

 

       term.  That's it.

 

                 Thank you.

 

                 CHAIRMAN DURST:  Does anyone have any

 

       comments or question on Catherine's presentation?

 

                 (No verbal response.)

 

                 CHAIRMAN DURST:  Okay.  We will move on

 

       then to the presentation from Dr. Joseph Murray,

 

       professor of medicine at the Mayo Clinic of

 

       Rochester, Minnesota, on the introduction to celiac

 

       disease.

 

                      INTRODUCTION TO CELIAC DISEASE

 

                 DR. MURRAY:  Good morning, Committee

 

       Members.  I will be providing a general overview to

 

       celiac disease.

 

                 (Slide.)

 

                 DR. MURRAY:  First of all, we will discuss

 

       what is celiac disease.  We will discuss, briefly,

 

       the pathogenesis of the disease; who gets it; what

                                                                 12

 

       the treatment is, at least in a very relatively

 

       superficial fashion.  We will discuss some of the

 

       complications and compliance issues of celiac

 

       disease and a prognosis or future of celiac

 

       disease.

 

                 (Slide.)

 

                 DR. MURRAY:  Obviously, yesterday was

 

       focused on food allergies.  "Celiac disease" is one

 

       of the food intolerances that is immune-mediated,

 

       though it is not thought to be IgE-mediated; so, it

 

       comes into the non-IgE-mediated food intolerances

 

       that are mediated by an immune response.

 

                 (Slide.)

 

                 DR. MURRAY:  Where does it happen?  It

 

       happens within the smaller intestine, predominantly

 

       the proximal, smaller intestine is the workhorse of

 

       the digestive system.  It is this surface of the

 

       intestinal lining that is maximally expanded by the

 

       development of circular folds and on top of these

 

       circular folds the so-called "villi," these villi,

 

       shown here in a histological picture, which

 

       maximize the digestive surface area.

                                                                 13

 

                 It is on the surface entrocytes of these

 

       villi that most of the enzymes and in the layer

 

       immediately above that in the lumen where most

 

       digestion of the macromolecules from nutrition are

 

       broken down and then absorbed.  This is just a

 

       picture.  It looks like one of those shag-ply

 

       carpets from the 1970s.  This is a normal

 

       appearance.

 

                 (Slide.)

 

                 DR. MURRAY:  However, celiac disease is an

 

       inflammatory state of the small intestinal mucosa.

 

       It occurs in those who are genetically predisposed,

 

       and it resolves, the damage resolves, with

 

       exclusion of dietary gluten.

 

                 Here, on the left, is a normal intestine

 

       with a normal villus structure; and on the right,

 

       fully evolved celiac disease with complete

 

       destruction.

 

                 The villi are gone, not only are they gone

 

       but this entire intestinal mucosa is greatly

 

       thickened and filled with inflammatory cells.  This

 

       is where the primary site of injury occurs in

                                                                 14

 

       celiac disease.

 

                 I didn't mention it, but it is a permanent

 

       condition.  While it will heal most of the time

 

       with exclusion of gluten, the intolerance to gluten

 

       is permanent and will recur when the individual is

 

       reexposed to gluten.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, what causes celiac

 

       disease?

 

                 (Slide.)

 

                 DR. MURRAY:  We know there are two major

 

       components to this disease: the first is the

 

       genetic background of predisposition.

 

                 Much of that predisposition revolves in

 

       the HLA type, which is part of our human leucocyte

 

       antigen-recognition system.  It is how we determine

 

       self- and non-self and generate an immune response

 

       as appropriate and its interaction with

 

       environmental factors, primarily the environmental

 

       factor of gluten.

 

                 These two conspire together to produce an

 

       immune response that becomes out of control

                                                                 15

 

       resulting in inflammation, which we just showed to

 

       you, that occurs primarily in the proximal small

 

       intestine and then subsequently the consequences of

 

       this inflammation leading to malabsorption and

 

       symptoms.

 

                 (Slide.)

 

                 DR. MURRAY:  What do we know about the

 

       genetics of the disease?  For many years, we know

 

       there is a strong, familial predisposition to the

 

       disease.

 

                 If you are unlucky enough to be a

 

       monozygous twin of somebody affected with celiac

 

       disease, your concordance rate is 80 percent.  It

 

       is not 100 percent, but it is about 80 percent.  If

 

       you are a sibling of a celiac, your chance of

 

       having it is 10 percent.  If you are a child of,

 

       about 5 to 10 percent.

 

                 There is a very strong association with

 

       certain HLA molecules.  These are Class II MHC

 

       molecules but particularly two types.  First, DQ2

 

       is the predominant type that is required for celiac

 

       disease, and in some populations DQ2 is also an

                                                                 16

 

       enabling type.

 

                 These genes, however, while they are

 

       essentially required for the disease, are not

 

       sufficient alone to the development of the disease.

 

       Probably 30 to 40 percent of the Caucasian

 

       population carry one or both of these molecules,

 

       but most of them don't get celiac disease.  There

 

       are other HLA genes that are likely involved,

 

       though they have not been well elucidated and

 

       certainly not confirmed in many populations.

 

                 There are other chromosomal disorders --

 

       Down's syndrome, Turner's syndrome, and Williams

 

       syndrome -- that are associated with a greatly

 

       increased risk of developing celiac disease for

 

       reasons that are not entirely clear, but probably

 

       are associated with the increase risk of disease in

 

       those chromosomal disorders.

 

                 (Slide.)

 

                 DR. MURRAY:  Looking at the primary

 

       environmental trigger for the disease -- that is,

 

       gluten -- it is basically the storage proteins that

 

       come from these particular cultivated grasses:

                                                                 17

 

       wheat, barley, rye, and other similar grains from

 

       within those families.  Other grasses -- for

 

       example, rice, items such as corn, sorghum, millet,

 

       and probably not even oats -- are not involved in

 

       triggering the disease.

 

                 (Slide.)

 

                 DR. MURRAY:  It is the storage proteins

 

       from the endosperm compartment of the wheat kernel

 

       particularly, and those are gliadins oar glutenins

 

       that are thought to contain the antigenic moieties

 

       that trigger the disease.

 

                 (Slide.)

 

                 DR. MURRAY:  What is it about these wheat

 

       proteins?  Well, if you take wheat, as an example

 

 

       of the others, these storage proteins are uniquely

 

       high in certain amino acids, especially glutamines

 

       and prolines.

 

                 Over 30 percent of the amino acids in

 

       gliadin are glutamines.  The glutamines, of course,

 

       can be cross-linked to give the grain its

 

       resiliency.  Really the cooking ability, the

 

       ability to use wheat as such an effective way of

                                                                 18

 

       making things that stick together like bread, for

 

       example, and maintain their shape, is largely a

 

       property of these particular combinations of amino

 

       acids.

 

                 The proline sequences that contain or

 

       proline residues contained within the wheat

 

       proteins also appear to form helices, and these

 

       helices are resistant to digestion within the

 

       mammalian gut.

 

                 (Slide.)

 

                 DR. MURRAY:  This may be a key factor in

 

       what results in the likelihood of these peptides

 

       basically being maintained and becoming, then,

 

       still available for the immune system to recognize

 

       in a patient with celiac disease.

 

                 Now, gliadin molecules are presented by

 

       these HLA types to T-cells in the intestine, and

 

       T-cells that are specifically primed to respond to

 

       gluten.  There are certain gliadin molecules that

 

       have a higher affinity than others for these

 

       Class II molecules and then the T-cell receptor.

 

                 These peptides may be processed or altered

                                                                 19

 

       within the gut, perhaps, to make them more

 

       antigenic.  They may not start out very antigenic,

 

       but then they undergo some change within the gut

 

       that may make them more antigenic.

 

                 It turns out that some of these peptides

 

       that are particular immunodominant, these are the

 

       ones that are most likely to produce an immune

 

       response, that those immunodominant peptides may be

 

       digestion resistant because they contain those

 

       proline sequences that perform helix, making them

 

       relatively poorly digestible by peptidases within

 

       the gut.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, it turns out that there

 

       is a contribution to this antigenic nature from

 

       within the intestine itself, and this may well be

 

       because of this enzyme tissue transglutaminase.

 

                 This is an enzyme that is present within

 

       the gut mucosa.  It is released by cells,

 

       especially fibroblasts when they become inflamed,

 

       and it cross-links cystine residues.

 

                 It turns out that it will also act on

                                                                 20

 

       gliadin by deamidating some of those glutamine

 

       residues, some specific glutamine residues, to

 

       glutamates, making it more antigenic by deamidating

 

       that gliadin peptide and making it fit more

 

       perfectly or with a tighter affinity into the

 

       binding groove of the DQ2-HLA molecule, and, hence,

 

       producing a more vigorous immune response within

 

       the gut.

 

                 (Slide.)

 

                 DR. MURRAY:  This is a schema, a

 

       relatively simplified schema, of what I have just

 

       talked about.  We start with wheat.  You look at

 

       particularly the ethanol-soluble fraction, and

 

       gliadin is probably broken up into smaller

 

       peptides, but still of a sufficient size to produce

 

       an immune response.

 

                 It is taken up across the epithelium

 

       presented by antigen presenting cells to the

 

       T-cells.  These are T-cells that will specifically

 

       respond to gluten then producing two types of

 

       responses: a cellular response, characterized by

 

       lymphocytes producing interferon gamma and possibly

                                                                 21

 

       other cytokines.  It is probably the cellular

 

       response that leads to the "inflammatory cascade"

 

       that produces the damaged epithelium characteristic

 

       of celiac disease.

 

                 It also produces help to the B-cell side,

 

       to produce plasma cells that produce antibodies.

 

       These antibodies are directed both against the

 

       exogenous antigen gliadin and also antibodies

 

       against tissue transglutaminase or what was known

 

       as an the endomysial antibody.  It is not known

 

       what the actual pathogenic role of this is, but it

 

       is a very useful serologic or blood marker for the

 

       disease.

 

                 I mentioned about the antigen getting

 

       changed by tissue transglutaminase.  This is a

 

       little cartoon which shows the peptide derived from

 

       gluten.  If you change one specific glutamine to a

 

       glutamic acid, which could be done by tissue

 

       transglutaminase, this then binds much more

 

       tightly.  This is the HLA molecule here on the

 

       surface of the antigen presenting cell, and it fits

 

       more perfectly into the T-cell receptor, producing

                                                                 22

 

       a more potent T-cell response.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, there are other things

 

       that happen in the setting of celiac disease, and I

 

       am really touching just on the surface of many of

 

       these, but there are other things that result in

 

       this inflammation that damage the lining of the

 

       intestine.

 

                 For example, there are metallic proteases

 

       that damage the structural elements that maintain

 

       the structure that maintain villus structure.

 

       There is endothelial injury that occurs affecting

 

       the blood vessels in the villus.  There are

 

       antibodies, autoantibodies, that are produced that

 

       affect actin that are involved in the site

 

       maintaining the structure of the entrocyte itself.

 

                 (Slide.)

 

                 DR. MURRAY:  Recently, there has been work

 

       suggesting that there is a molecule called

 

       "zonulin" that may be released in the setting of

 

       celiac disease.

 

                 This is important because it opens up

                                                                 23

 

       tight junctions between entrocytes which may allow

 

       even more ready access of the antigen, the foreign

 

       antigens, between the cells into lamina propria

 

       where antigen-presenting cells can then present

 

       those peptides to the gluten-responsive T-cells,

 

       further accelerating the disease.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, I pointed out that many

 

       people, 30 percent or more of the Caucasian

 

       population, carry DQ2 or DQ8.  Virtually, the

 

       entire population are exposed to gluten, but most

 

       people don't get the disease.

 

                 There must be triggers that produce the

 

       disease.  There is evidence that suggests that

 

       gluten in the infant diet, specifically the age of

 

       introduction of gluten into the infant's diet, may

 

       be important in triggering or at least producing

 

       autoantibody markers suggestive of celiac disease

 

       early in life.

 

                 It is not clear, however, if that changes,

 

       whether you delay introduction or not whether that

 

       changes, the lifetime risk of celiac disease, but

                                                                 24

 

       it certainly seems to be important in triggering or

 

       producing evidence in childhood at least of celiac

 

       disease immune markers.

 

                 The amount of gluten in the child's diet

 

       may be important.  There are other events such as

 

       pregnancy, infection, or surgeries that may bring

 

       previously asymptomatic celiac disease to clinical

 

       presentation.

 

                 (Slide.)

 

                 DR. MURRAY:  One could speculate, and I

 

       think this is based on some data, putting data

 

       together, that one's risk for celiac disease starts

 

       with your HLA type.  Only those who carry HLA types

 

       are at risk.  You, then, are exposed to gluten.

 

       Perhaps the timing of exposure is important,

 

       developing in some individuals a sensitivity to

 

       gluten.

 

                 Then, with the interaction of other

 

       factors such as other genes other than HLA, other

 

       things that may predispose one to autoimmunity

 

       including gender and other events that may occur --

 

       gastroenteritis, aging, postsurgical or postpartum

                                                                 25

 

       changes in the immune system that may occur -- may

 

       lead to a loss of tolerance, inflammation, and

 

       subsequent malabsorption.

 

                 (Slide.

 

                 DR. MURRAY:  Don Kasarda, who is here once

 

       used the term or suggested that celiac disease was

 

       a collision between our evolution of our immune

 

       system and our ability to recognize self and

 

       non-self through the HLA system and our cultivation

 

       of wheat and these other grasses.  This collision

 

       occurs in the intestine.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, when this collision

 

       occurs and results in damage, how does it present?

 

       And who gets the disease?

 

                 (Slide.)

 

                 DR. MURRAY:  Well, this is classic celiac

 

       disease, and this is the way that I certainly

 

       learned about celiac disease.  A severe

 

       malnourished child with evidence of malnutrition

 

       often associated with the large, swollen abdomen

 

       but great muscle, terrific muscle, wasting and

                                                                 26

 

       protein-calorie malnutrition with symptoms that

 

       would occur sometime after the onset of gluten

 

       introduction into the diet, sometime between the

 

       age of six months and seven years of age: with

 

       failure to thrive; abdominal distention; anorexia;

 

       diarrhea; steatorrhea, that is the passage of

 

       malabsorptive stools laden with fat; anemia; growth

 

       failure; and vitamin deficiencies.  That was really

 

       the picture that we had of celiac disease 30 years

 

       ago.

 

                 (Slide.)

 

                 DR. MURRAY:  However, we now see celiac

 

       disease in adulthood.  In fact, celiac disease can

 

       present at any age.  Symptoms can include things

 

       such as abdominal pain, even upper-GI symptoms:

 

       heartburn, nausea, vomiting, anemia, fatigue.

 

                 There are of course patients who have

 

       symptoms of malabsorption, though not necessarily

 

       the classic, fully evolved malabsorptive picture.

 

       Steatorrhea as a presenting symptom is relatively

 

       rare, even patients may have constipation.

 

                 (Slide.)

                                                                 27

 

                 DR. MURRAY:  It can mimic other disorders

 

       such as lactose intolerance.  Indeed, lactose

 

       intolerance may be secondary to the damage caused

 

       by celiac disease.  It may mimic the symptoms of

 

       irritable bowel syndrome or symptoms of

 

       inflammatory bowel disease.

 

                 (Slide.)

 

                 DR. MURRAY:  There are specific

 

       deficiencies that can occur in celiac disease,

 

       especially the fat-soluble vitamins -- D, E, A,

 

       and K -- with their resultant syndromes from

 

       deficiencies.

 

                 Iron deficiency is especially common in

 

       celiac disease because iron is absorbed in the

 

       proximal small intestine; folate deficiency, again,

 

       because it is absorbed in the proximal small

 

       intestine; and, interestingly, B12 deficiency may

 

       be relatively common in celiac disease by a variety

 

       of mechanisms.  Other trace elements -- zinc, B6,

 

       selenium, and others -- may also be deficient in

 

       celiac disease.

 

                 While in the past we would look for

                                                                 28

 

       combinations of these, often a patient would

 

       present with many of these deficiencies at the time

 

       of diagnosis, now it is relatively uncommon to see

 

       the entire spectrum of deficiencies.  Indeed, you

 

       usually see one or two deficiencies that are

 

       clinically evident, and the others may not even be

 

       present.

 

                 (Slide.)

 

                 DR. MURRAY:  How about non-intestinal?  I

 

       have mentioned that the major site of injury is in

 

       the gut, but there are patients who will present

 

       with non-intestinal presentations which can involve

 

       into things such as the musculoskeletal system,

 

       joint pains and osteoporosis or osteomalacia;

 

       infertility or reproductive issues, delayed

 

       puberty, spontaneous recurrent abortions have been

 

       described; hematologic, which is predominantly

 

       anemia; hyposplenism is an unusual consequence but

 

       can present; and then dentition, enamel defects,

 

       can be a presenting feature.

 

                 (Slide.)

 

                 DR. MURRAY:  To focus on iron deficiency

                                                                 29

 

       anemia, which is probably one of the most common

 

       reasons that I see celiac disease, about 5 to 8

 

       percent of adults who present with unexplained iron

 

       deficiency in some studies have celiac disease.

 

                 It is especially common in those who are

 

       resistant to the use of oral iron.  If you look at

 

       individuals who are coming to gastroenterologists

 

       for endoscopy, it may be 5 to 15 percent of those

 

       patients, depending on the study, who may have

 

       celiac disease if biopsies are taken from the small

 

       intestine.

 

                 However, many of those patients are even

 

       missed because the biopsies are still not taken

 

       during routine endoscopy in patients who have got

 

       anemia in about a third to a half of patients.

 

                 (Slide.)

 

                 DR. MURRAY:  Osteomalacia or bone disease,

 

       this is an example of severe disease with

 

       pseudofractures in the pelvis of an individual,

 

       whose only presentation was osteomalacia with no GI

 

       symptoms, caused by celiac disease.

 

                 Other non-intestinal presentations include

                                                                 30

 

       neurologic or even neuropsychiatric syndromes such

 

       as neuropathy, ataxia, seizures, cognitive decline,

 

       or dementias; fibromyalgia-like syndromes or

 

       chronic fatigue syndrome-like presentations;

 

       individuals with skin and mucous membranes, there

 

       is a specific rash associated with celiac disease,

 

       a recurrent aphthous ulceration of the mouth; the

 

       dental enamel defects we mentioned.

 

                 (Slide.)

 

                 DR. MURRAY:  And, then, dermatitis

 

       herpetiformis was specifically mentioned, because

 

       this very blistering, extremely itchy skin rash

 

       that affects the extensor surfaces is a direct

 

       manifestation of intestinal gluten sensitivity.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, what about other

 

       associated conditions?  Celiac disease is

 

       associated with other autoimmune conditions.  It

 

       may be seen in 3 to 7 percent of Type I diabetics,

 

       individuals with thyroid disease, individuals with

 

       inflammatory arthritis, primary biliary cirrhosis,

 

       as examples of others; and then the congenital

                                                                 31

 

       disorders, especially those associated with

 

       chromosomal abnormalities and also selective IgA

 

       deficiency.  If you look at relatives of celiacs,

 

       it is anywhere between 5 to 20 percent, depending

 

       on how one is related to someone with celiac

 

       disease.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, beyond the symptomatic

 

       celiac disease, there are also individuals who have

 

       no symptoms, who already have fully evolved damage

 

       within their intestine, and there may be no symptom

 

       or there may not be occurring in someone with an

 

       associated disease.

 

                 This is frequent to find this in first-

 

       and second-degree relatives of patients with celiac

 

       disease.

 

                 (Slide.)

 

                 DR. MURRAY:  There is also what is termed

 

       "latent" -- well, whether it is latent celiac

 

       disease or latent gluten sensitivity -- individuals

 

       who have a positive serologic response but have a

 

       negative small-bowel biopsy.  Some of those

                                                                 32

 

       patients will go on to develop the full-blown

 

       disease, if followed, on a normal diet.

 

                 (Slide.)

 

                 DR. MURRAY:  What about the epidemiology?

 

       To summarize, while it was first identified in

 

       Europe, it occurs essentially in all populations,

 

       which could be termed Caucasian.  Its prevalence is

 

       probably somewhere between 1 in 90 to 1 in 300;

 

       however, the diagnosis rate is much lower, which

 

       would suggest a prevalence of about 1 in 2,000, if

 

       you just look at the diagnosed cases.

 

                 It is one of the most frequent genetically

 

       based diseases.  If you look at other countries --

 

       Latin America, or other areas; Africa, especially

 

       North Africa; if you look at Asian countries --

 

       there is celiac disease present in those.  The

 

       worldwide average prevalence is somewhere very

 

       close to 1 percent.

 

                 (Slide.)

 

                 DR. MURRAY:  I'm coming a little closer to

 

       home.  This is the data from Olmsted County, that

 

       we published a couple of years ago, which looked at

                                                                 33

 

       the new case identification or the incidence rate.

 

                 The solid yellow line is the new cases per

 

       100,000 in the population, which is essentially

 

       quite low and stable over many decades until the

 

       1990s and into 2000 to 2001, showing a greatly

 

       increased rate of detection of celiac disease.

 

                 If we looked at who were being diagnosed,

 

       this is the age of diagnosis by age category.  This

 

       is the incidence per 100,000 of people in that age

 

       category in the community.  You can see that the

 

       new cases being diagnosed are predominantly people

 

       between the age of 45 and 64.

 

                 The solid line indicates females; so,

 

       females are diagnosed at a rate about twice that of

 

       males of all ages.

 

                 There are a significant portion of

 

       individuals, almost a third, who were diagnosed for

 

       the first time over the age of 65.

 

                 (Slide.)

 

                 DR. MURRAY:  One can term or consider

 

       celiac disease like an iceberg.  These are a series

 

       of icebergs where the tip of the iceberg is the

                                                                 34

 

       part that has been detected, and the part

 

       underwater is the part that can be found if one

 

       screens the population.  Of note, these are numbers

 

       per thousand not percent.

 

                 Obviously, there are some places like

 

       Ireland, for instance, which is quite a big iceberg

 

       with a lot above water but also a lot below water.

 

       Finland, which this iceberg is probably even more

 

       out of the water as they have got a very active

 

       program for finding celiac disease.

 

                 This is circa 1996.  The U.S.A. iceberg is

 

       still close to a very low level of actually being

 

       diagnosed; but this number, the part underwater,

 

       has actually grown to be something very close to

 

       what you would find in Finland or Ireland,

 

       especially when one looks at, at least what we know

 

       about is really from a Caucasian population.

 

                 (Slide.)

 

                 DR. MURRAY:  One miniature study, this is

 

       one we simply looked at, Natrona County in Wyoming.

 

       This is a very isolated community.  Anybody who has

 

       been to Wyoming, there is lots of nothing for miles

                                                                 35

 

       and miles.

 

                 We were able to study about 4,000

 

       individuals from a health fair, generally healthy,

 

       and found the numbers above just under 1 percent of

 

       people who had serologic evidence for celiac

 

       disease.

 

                 Only half of them had GI symptoms.  Most

 

       of them did not have other risk factors for celiac

 

       disease, just two having family members with celiac

 

       disease.

 

                 However, these are numbers that would

 

       confirm basically the rest of the world's data that

 

       suggests that the prevalence of celiac disease, if

 

       you look for it, is probably slightly under

 

       1 percent.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, how does one make the

 

       diagnosis?  It starts with suspicion.  Serologic

 

       tests may be very effective at detecting the

 

       disease.  The intestinal biopsies are regarded as

 

       the gold standard.  Then, one ultimately gets a

 

       response to a gluten-free diet to confirm the

                                                                 36

 

       diagnosis.

 

                 (Slide.)

 

                 DR. MURRAY:  The pathology, as we have

 

       mentioned already, is a pathology of chronic

 

       inflammation within the intestine with features

 

       such as intraepithelial lymphocytes on the surface,

 

       villus atrophy or the loss of the villus surface,

 

       great crypt hyperplasia, and then characterized by

 

       being a lamina propria filled with lymphocytes,

 

       macrophages, plasma cells, and even eosinophils.

 

                 (Slide.)

 

                 DR. MURRAY:  There is however a spectrum

 

       of damage that occurs, typified here by the Marsh

 

       classification.  This is classic disease, but there

 

       are also milder forms of the disease that may be

 

       asymptomatic in most individuals.

 

                 (Slide.)

 

                 DR. MURRAY:  Our algorithm for finding

 

       celiac disease, if we have a high clinical

 

       suspicion, an individual with malabsorption, we

 

       biopsy those individuals.  If we have an individual

 

       who is at moderately increased risk, serology is

                                                                 37

 

       probably the most effective way of finding it.

 

       Though, we yet do not depend on the serology alone

 

       to detect this, there are other circumstances for

 

       alternate; serologic testing may be necessary.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, what about treatment for

 

       celiac disease, or, as one patient with celiac

 

       disease called it, "playing gluten-free roulette"?

 

                 (Slide.)

 

                 DR. MURRAY:  The nuts and bolts of a

 

       gluten-free diet, basically one needs to avoid

 

       foods that contain the offending grains: wheat,

 

       barley, rye, and the wheatlike grains of spelt and

 

       kamut.

 

                 I put down at the bottom that many corn or

 

       rice commercial cereals do not appear to be

 

       gluten-free because of their incorporation of

 

       particularly barley extract in their flavor

 

       ingredients.

 

                 (Slide.)

 

                 DR. MURRAY:  Now, one of the issues and of

 

       course the issue for today is, How much gluten is

                                                                 38

 

       too much?  We will be hearing a lot more when you

 

       hear prospective and retrospective data later this

 

       morning on this.  I am not going to dwell on it.

 

                 One thing from clinical appreciation is

 

       that symptoms are not a good indicator of gluten

 

       ingestion.  Many patients can have significant

 

       damage to their intestine, despite the absence of

 

       symptoms when they ingest gluten.

 

                 Most patients diagnosed clinically with

 

       celiac disease have never suspected that wheat or

 

       gluten products are what are precipitating their

 

       symptoms.  They may have or are often likely to

 

       have blamed other foods that they weren't able to

 

       digest because of the damage.

 

                 Antibodies such as tissue transglutaminase

 

       antibodies are really only positive of the

 

       substantial gluten contaminating the diet.  At

 

       least in my practice if somebody admits to cheating

 

       more than once a month they will like continue to

 

       have injury in their gut.  However, there is a high

 

       degree of variability in the sensitivity to gluten

 

       ingestion, at least clinically.

                                                                 39

 

                 (Slide.)

 

                 DR. MURRAY:  We will hear a little bit

 

       about Codex Alimentarius draft standards.  This,

 

       however, is still a draft, I think a Stage IV

 

       draft.  I want to put this up really to demonstrate

 

       that there is a variance between countries and what

 

       one allows.

 

                 We will hear more from our colleagues from

 

       Europe about some of the incorporation of rendered

 

       gluten-free foods which use the gluten-containing

 

       grains as a base and then remove the proteins from

 

       them.

 

                 (Slide.)

 

                 DR. MURRAY:  What about non-responsive

 

       celiac disease?  This is relatively common.  By

 

       far, the most common reason is inadvertent gluten

 

       contamination of the diet and lymphocytic colitis,

 

       pancreatic insufficiency, bacterial overgrowth, and

 

       then only a few patients have true refractory

 

       disease that no longer responds to exclusion of

 

       gluten from the diet.

 

                 (Slide.)

                                                                 40

 

                 DR. MURRAY:  There are many potential

 

       sources of contamination of the diet with gluten,

 

       which include of course commercial cereals, eating

 

       out, communion wafers, lipstick, airborne flour or

 

       starch in certain work situations, so-called "soy"

 

       sauces made from wheat, mislabeled or unlisted

 

       ingredients have been an issue, and at least

 

       allegedly some medications.

 

                 (Slide.)

 

                 DR. MURRAY:  Some ingredients that people

 

       are concerned about: seasonings and spice blends,

 

       modified food starch, malt and malt extract,

 

       modified hop extract or yeast-malts, sprout

 

       extract, dextrins, caramel color.  There are a

 

       whole bunch of things that might be derived from

 

       gluten-containing grains.

 

                 (Slide.)

 

 

                 DR. MURRAY:  What about complications

 

       associated with untreated celiac disease?  We know

 

       the mortality of symptomatic celiacs who do not

 

       comply with the diet has doubled.  The mortality of

 

       celiac disease even when it is diagnosed is also

                                                                 41

 

       double, even following out for several years after

 

       the diagnosis.

 

                 The predominant excess in death comes from

 

       GI malignancies.  There are also morbidity

 

       consequences such osteoporosis or osteomalacia,

 

       stunted growth, infertility, chronic ill-health --

 

       all of which could be prevented by early detection

 

       and treatment.

 

                 (Slide.)

 

                 DR. MURRAY:  What are the dangers of

 

       non-compliance?  The increased mortality we

 

       discussed, the osteoporosis.  Children who were

 

       diagnosed and then did not remain on a gluten-free

 

       often have osteoporosis or diminished bone density

 

       when they get to adulthood, lymphoma, other

 

       cancers, and then the psychological effects of

 

       non-compliance.

 

                 (Slide.)

 

                 DR. MURRAY:  One of the most feared

 

       complications of this are the T-cell lymphoma.

 

       This is celiac disease on this side, and the T-cell

 

       lymphoma on the other side is one of the more

                                                                 42

 

       feared complications with a very high mortality.

 

                 (Slide.)

 

                 DR. MURRAY:  However, as I pointed out,

 

       most celiac disease is probably not symptomatic, at

 

       least when we look at a cross-section of the

 

       population.  We do not know whether those

 

       identified by screening are less sick than

 

       clinically diagnosed celiac disease.

 

                 We don't know the benefit or negative

 

       effects of a gluten-free diet in those who are

 

       found by screening alone.  We don't know if they

 

       are any more or less likely to comply with a

 

       gluten-free diet.  We don't know whether

 

       intervening in those patients will actually affect

 

       their ultimate mortality.

 

                 (Slide.)

 

                 DR. MURRAY:  George Dennison Prentice

 

       said, "What come call health, if purchased by

 

       perpetual anxiety about diet, isn't much better

 

       than tedious disease."

 

                 (Slide.)

 

                 DR. MURRAY:  This comes to the future. 

                                                                 43

 

       There is, I think, a promising future in celiac

 

       disease, a variety of approaches, which I have

 

       listed, that individuals and research groups are

 

       looking at as alternates to the gluten-free diet,

 

       though none of them are really even close to

 

       clinical use.

 

                 (Slide.)

 

                 DR. MURRAY:  This is one that has been

 

       tested in patients using a lactobacillus digestion

 

       strategy, trying to reduce the potential, harmful

 

       effects of gluten.

 

                 In summary, I would like to suggest that

 

       gluten or celiac disease is common.  It has been

 

       largely unrecognized until recently.  There are

 

       many challenges that face patients and their

 

       physicians in the treatment.

 

                 The gluten-free diet is not simple.  There

 

       is widespread use of grain proteins in good, and

 

       that makes it challenging for individuals with

 

       celiac disease.  Food ingredient source

 

       identification is of great concern to patients.

 

                 Dietitians and those who counsel patients

                                                                 44

 

       with celiac disease, we are here because of

 

       regulation or potential regulations.  Defining

 

       acceptable thresholds and verification of those may

 

       be very important to patients with celiac disease.

 

                 (Slide.)

 

                 DR. MURRAY:  I finish with an aside on

 

       another food safety issue, an invitation to come to

 

       Minnesota and enjoy Joe's and have worms at the

 

       same time.

 

                 Thank you.

 

                 CHAIRMAN DURST:  Thank you very much,

 

       Dr. Murray.

 

       QUESTION-AND-ANSWER SESSION

 

                 CHAIRMAN DURST:  I would like to ask the

 

       Committee if they have any questions or discussion,

 

       and also to point out that Dr. Murray will not be

 

       able to stay around for discussion this afternoon.

 

       If there are questions, now is the time to ask

 

       them.

 

                 Doug.

 

                 DR. HEIMBURGER:  Thank you very much for

 

       that presentation.  It is very helpful.  I do care

                                                                 45

 

       for some patients with celiac disease.  As you

 

       already mentioned, one of the big questions that

 

       they have is, "What really are my risks if I play

 

       with it a little bit?  If I knowingly introduce a

 

       little bit of gluten in my diet, how absolutely

 

       obsessive do I need to be about it?"

 

                 With the mortality being primarily

 

       associated with the risk of lymphoma, what is the

 

       quality of the evidence that compliance with gluten

 

       restriction is really correlated with the risk of

 

       lymphoma?

 

                 DR. MURRAY:  The evidence, the quality of

 

       the evidence is largely observational, taking

 

       cohorts and following them, and often their

 

       self-assessment of their level of compliance.  The

 

       data is based on those cohorts.  They are

 

       predominantly referral cohorts.

 

                 The longest follow up comes from Britain.

 

       In those, there is quite a clear increased risk not

 

       just for lymphoma but other malignancies in those

 

       who are considered not to be completely compliant

 

       with the diet.  I would say the level of evidence

                                                                 46

 

       while it is not a prospective study, in retrospect

 

       in fact it appears to be reasonably strong.

 

                 DR. BRILEY:  Margaret Briley.  I would

 

       like to know what you can tell us what might be the

 

       reason for the increased detection of celiac

 

       disease?  Is the serological test the definitive

 

       reason?  What is going on with those?  It seems to

 

       be more prevalent, as you said, in our society.

 

 

                 DR. MURRAY:  I think there are probably

 

       two reasons, one is probably serologic detection

 

       has made this an acceptable diagnosis to primary

 

       care physicians, number one; and the second is

 

       suspicion, that is, the awareness of celiac disease

 

       as a possibility.

 

                 I do not believe, however, we can rule out

 

       the possibility that celiac disease is actually

 

       increasing in prevalence over time.

 

                 We don't know, but we know that there

 

       certainly were substantial increases in other

 

       inflammatory bowel diseases over the last 50 years,

 

       which may not have been accounted for by detection

 

       rates, for example.

                                                                 47

 

                 I do agree with you it is probably the

 

       sero-detection.  It is a combination of those two

 

       things, suspicion and ease of detection have made

 

       the biggest difference.  However, I would not rule

 

       out the possibility of its actually increasing in

 

       prevalence.

 

                 CHAIRMAN DURST:  Soheila.

 

                 DR. MALEKI:  Soheila Maleki.  I was

 

       wondering how long does a person that is

 

       asymptomatic go before they find they are

 

       symptomatic?  How do they usually find out?

 

                 DR. MURRAY:  First of all, we don't know

 

       when it starts.  There is one study I didn't talk

 

       about from Denver that suggested that children, if

 

       you follow children at genetic risk for celiac

 

       disease based on HLA type, that they will convert,

 

       sero convert, by about the age of seven, though

 

       most of them are asymptomatic.

 

                 It reaches all but 1 percent of that

 

       childhood cohort, the same prevalence you find if

 

       you look at adults.  The suggestion is that you

 

       have developed that celiac autoimmunity probably by

                                                                 48

 

       the age of seven.

 

                 However, the age, the median age, of

 

       diagnosis is 45 years of age.  It is likely that

 

       those individuals have some clinical disease for a

 

       long time before they present.

 

                 In our population, the most common reason

 

       for presentation is postmenopausal anemia.  Women

 

       who have anemia sometimes go a long time,

 

       especially when they are menstruating.  The doctor

 

       says that menstruating is an excuse for the anemia.

 

       Now that they are menopausal and are no longer

 

       menstruating they no longer have an excuse for

 

       their anemia, and they are referred for evaluation

 

       for the cause of anemia.

 

                 Iron deficiency anemia at least is one of

 

       the most common, but there are other things.  For

 

       example, the development of chronic GI symptoms.

 

       Largely, as the earlier questioner said, probably

 

       awareness of the possibility of this disease, with

 

       primary care doctors using sero-diagnosis to find

 

       celiac disease.

 

                 There a lot of atypical symptoms.  There

                                                                 49

 

       are reservoirs of celiac disease, the Type I

 

       diabetics, the family members of celiacs, those

 

       with chromosomal disorders.  As the doctors looking

 

       after those people become more aware of celiac

 

       disease, they are testing their patients more.

 

DR. BRILEY:  Could you speak a little bit more about

 

       the evidence that you have in regard to physicians

 

       using the serological test?  Is it a pretty common

 

       thing to do it at the very beginning of a patient's

 

       coming in with GI problems, or is it more likely it

 

       is down the road a while?

 

                 DR. MURRAY:  If you look at the data on

 

       patients’ presentation time, from presentation to

 

       diagnosis of celiac disease, it is somewhere

 

       between 8 and 11 years from the time they present

 

       to their physician with a complaint to the time

 

       their diagnosis is made.

 

                 I think that time period is now beginning

 

       to shorten, thankfully.  The serology is done close

 

       to the end of that period, so it is often only when

 

       the suspicion is generated.  Partly that is because

 

       it is not considered at the early differential

                                                                 50

 

       diagnosis of celiac disease.

 

                 It is also difficult.  It is difficult

 

       because the symptoms are not very specific.

 

       Fatigue and some bowel disturbance and a little

 

       anemia, that is not a rare syndrome or not a rare

 

       collection of symptoms you will see in individuals

 

       in our community.  It is hard to know where you

 

       look for celiac disease and when you look for it.

 

       It is often a very delayed diagnosis.

 

                 DR. BRILEY:  Is the serological test one

 

       that is pretty accurate?  Could one count on it if

 

       you did it early?

 

                 DR. MURRAY:  If you use the more modern

 

       autoimmune tissue transglutaminase test, for

 

       example, it is reasonably good.  It is not perfect,

 

       but it is quite efficient at detecting celiac

 

       disease at that level, in that period.  It is not

 

       perfect, though, but it is a pretty good test.

 

                 DR. BRILEY:  It sounds like we need to do

 

       some education, then.

 

                 DR. HEIMBURGER:  A follow up to that --

 

       Doug Heimburger -- what is currently understood to

                                                                 51

 

       be the sensitivity specificity of anti-tissue

 

       transglutaminase antibodies?

 

                 DR. MURRAY:  Depending on the study, most

 

       studies suggest that the sensitivity of tissue

 

       transglutaminase for celiac disease is in the high

 

       90 percent, so the high 90s.

 

                 The specificity is probably also in the

 

       mid- to high 90s, so quite effective when you are

 

       looking at a population you are suspicious of the

 

       disease.

 

                 DR. BRILEY:  One more question.

 

       Margaret Briley.  Do we have any data that shows

 

       the celiac patient also maybe has been identified

 

       with a lactose intolerance?  Is there anything that

 

       combines those two that you would know or does

 

       that--?

 

                 DR. MURRAY:  The combination is probably

 

       the damage that is caused by celiac disease, the

 

       damage to the entrocytes affects your disaccaridase

 

       including lactase throughout the surface of the

 

       small bowel, and, hence, you get a secondary

 

       lactose intolerance.

                                                                 52

 

                 In general, if you think of the genetic

 

       basis or the ethnic groups that are involved,

 

       celiac disease tends to hit those of European

 

       extraction more so.  I know that population will

 

       tend to retain their lactase activity for longer.

 

                 If you look at Subsaharan Africans, for

 

       example, we don't know actually what the prevalence

 

       of celiac disease is in Subsaharan Africans, but

 

       they are individuals who tend to lose their

 

       lactase.

 

       Genetically, they are probably separate, but they

 

       come together because of secondary lactase

 

       deficiency caused by the damage in celiac disease.

 

                 DR. NELSON:   Thank you, Dr. Murray.  That

 

       really was a very interesting presentation.  I

 

       think the last time I studied this was 30 years

 

       ago.

 

                 CHAIRMAN DURST:  Identify yourself,

 

       please.

 

                 DR. NELSON:  Mark Nelson.  I wanted to

 

       touch base on the couple of slides where you talked

 

       about how much gluten is too much and the proposed

                                                                 53

 

       Codex definition for gluten-free foods.

 

                 You had a question mark after the

 

       threshold for damage being 20 to 100 milligrams per

 

       day, and I guess that is similar to the naturally

 

       gluten-free foods the Codex proposed.

 

                 Then, it goes on to talk about cheating is

 

       greater than once per month.  Also, is there an

 

       issue of cumulative exposure, 20 milligrams per

 

       day, or is the cheating an excursion of whole wheat

 

       crackers, for example?

 

                 DR. MURRAY:  Well, first of all, the

 

       comment on cheating that is what the patients tell

 

       me, those patients who will admit to gross

 

       cheating, that is, eating a piece of bread or a

 

       cookie or cake, which is what I regard as an

 

       obvious source of gluten.

 

                 However, that may reflect some other

 

       background, but a lack of detail of care, for

 

       example, attention to detail in the rest of their

 

       diet, maybe what they are not telling us.  That

 

       only applies to what they have told me.

 

                 The issue of actual threshold, I have a

                                                                 54

 

       question mark after that because we will hear a lot

 

       more detail, science, about threshold testing for

 

       thresholds of gluten contamination.

 

                 The intermittent contamination, once a

 

       month obvious contamination.  Something that is, to

 

       some degree, under the patient's control with

 

       appropriate education and exposure to information

 

       then essentially it is under their control.

 

                 It is the low-level contamination on a

 

       regular basis from sources they are not aware of,

 

       and those are the patients that I see that make up

 

       the majority of the patients I see who have

 

       difficulty.  They are coming to me because they are

 

       trying to be gluten-free, but they are having

 

       contamination of their diet on a daily basis,

 

       probably a relatively small amount.  We will hear a

 

       lot more about the threshold, the actual testing of

 

       the threshold using that type of low-level daily

 

       contamination.

 

                 DR. MALEKI:  Soheila Maleki.  Is there an

 

       adult onset or spontaneous development of celiac

 

       disease, or does this have to come with a genetic

                                                                 55

 

       component and hereditary?

 

                 DR. MURRAY:  It probably only occurs in

 

       people who have that HLA or genetic type.  You have

 

       to have it.  However, that is 30-plus percent of

 

       the Caucasian population.

 

                 Can it start first in adulthood?  We have

 

       very little data on that.  The only data is the

 

       stuff I have mentioned, looking at children and

 

       showing about 1 percent by the age of seven or

 

       eight, positive by the age of seven or eight, the

 

       same prevalence if you look at adulthood.

 

                 There are a few cases of what we call

 

       "latent celiac disease," individuals who have got

 

       antibodies with apparently normal small intestinal

 

       biopsies as adults, then go on over a space of

 

       years to develop full-blown celiac disease within

 

       years of that initial identification of a positive

 

       serology.  Those are very rare cases that have been

 

       found.

 

                 Of course, if you find somebody who

 

       suspects they have got a problem, they ought to

 

       change their diet anyway, and that changes

                                                                 56

 

       everything.  There is very little data, I think, to

 

       be sure of whether it first occurs, starts, in

 

       adulthood.

 

                 If you look at the age of diagnosis, your

 

       eighth or ninth decade can be the first time that

 

       you are diagnosed with celiac disease.  A lot of

 

       those patients have suspicious symptoms going back

 

       many years.

 

                 DR. BRITTAIN:  Erica Brittain.  Can you

 

       quantify the level of damage?  Is that only

 

       possible with the biopsy, and is that very

 

       invasive?

 

                 DR. MURRAY:  You can -- well, if you take

 

       biopsies, you can quantify the degree of injury.  I

 

       showed that slide which shows a spectrum of injury.

 

       It tends to be variable, even within the same

 

       individual.  It started in the first part of the

 

       small intestine and extends a variable distance

 

       down the small intestine.

 

                 There has really only been one study,

 

       which was done in the early 1960s, of taking

 

       multiple biopsies down the intestine -- a handful

                                                                 57

 

       of courageous volunteers.

 

                 It is not clear that there is a

 

       correlation between the extent of injury and the

 

       severity of symptoms.  In fact, we don't know how

 

       to predict the occurrence of symptoms in patients

 

       with celiac disease, so that is a "black box."

 

                 DR. BRITTAIN:  You are saying there is

 

       really no simple way to quantify the extent of

 

       damage?  There is nothing that would correlate with

 

       these multiple biopsies?

 

                 DR. MURRAY:  Some people have suggested

 

       that the level of the antibodies, the tighter the

 

       antibodies might correlate:  The higher, the

 

       tighter, maybe the more severe the injury to the

 

       intestinal biopsies.

 

                 When we take a biopsy of the intestine, we

 

       are sampling a tiny fraction of a percentage of

 

       1 percent, a fraction of 1 percent, of the

 

       intestinal lining.  We have tried to look using

 

       other imaging techniques to assess the extent of

 

       injury.  Using some of those techniques seems to be

 

       very variable between individuals, and it doesn't

                                                                 58

 

       seem to predict their symptoms.

 

                 Really right now it is a yes or no issue:

 

       yes, they have celiac disease; or, no, they do not.

 

       It is very hard to measure the severity of the

 

       disease.

 

                 We can look at the severity of

 

       consequences: have they developed osteoporosis,

 

       what their bone density is, have they lost a lot of

 

       weight, whether they have severe malabsorption

 

       based on fat malabsorption in their stool.  We have

 

       got other measures to look at the consequences or

 

       impact of the disease, those we can assess.

 

                 DR. BRITTAIN:  Do you think that it would

 

       correlate with the intestinal damage?  Not

 

       necessarily?

 

                 DR. MURRAY:  We have tried.  I would say

 

       that the data is not very good on that.  People

 

       with very mild injury may be more likely to be

 

       asymptomatic, but the data is not sound.

 

                 CHAIRMAN DURST:  Suzanne.

 

                 DR. MALEKI:  Suzanne Teuber.  I had a

 

       question about the neurologic presentations.  I

                                                                 59

 

       have read some on screening of pediatric

 

       populations, but with adults how often does it

 

       present as dementia without it being diagnosed as a

 

       GI problem?  Is this something we should be adding

 

       to dementia screening?

 

                 DR. MURRAY:  It is probably relatively

 

       rare.  In fact, I think there has only been one

 

       good study.  Maybe Dr. Collin, who is here as a

 

       speaker later, has done a study and has looked at

 

       and reported on that.

 

                 We occasionally see cognitive decline at

 

       the time of diagnosis, but there is really no good

 

       epidemiologic study to address that.  Some of the

 

       other presentations, peripheral neuropathy, for

 

       example, or ataxia, there is more data on it.  Many

 

       neurologists are beginning to include celiac

 

       disease as part of their differential diagnosis for

 

       those syndromes.  Good epidemiology data is

 

       relatively small, very little data.

 

                 CHAIRMAN DURST:  Ciaran.

 

                 DR. KELLY:  Ciaran Kelly.  This is

 

       actually more clarification than a question.  Dr.

                                                                 60

 

       Murray is quite correct that there isn't a measure

 

       of either severity of intestine abnormality or even

 

       height of antibody levels that reliably reflects

 

       the degree of injury or correlates closely with

 

       symptomatology.

 

                 However, with treatment one can use a

 

       decline in antibody levels as a crude indicator of

 

       at least reduced exposure to gross amounts of

 

       gluten.  It is not a very sensitive indicator, but

 

       it is useful.  Of course, with repeat biopsy, if

 

       the histology has revered to normal, that of course

 

       can be used.  However, the less invasive test of

 

       following antibody levels is used clinically to

 

       follow response.

 

                 DR. MURRAY:  Quite right.  I think you

 

       will agree, Joe.

 

                 DR. KELLY:  If the antibody levels aren't

 

       dropping, that is used as an indication that the

 

       patient is successfully on a gluten-free diet.

 

                 DR. BRILEY:  Margaret Briley.  Can you

 

       give us any idea of any behavior data that you may

 

       have received from your patients regarding their

                                                                 61

 

       willingness to try foods that are not gluten-free

 

       labeled?

 

                 DR. MURRAY:  Oh, well, there are many

 

       different attitudes among patients with regard to

 

       what they want to eat or what they are afraid to

 

       eat.

 

                 I advise my patients to be prudent, that

 

       they try to select things based on identification

 

       of ingredients, source ingredients, not containing

 

       things contained from gluten, the use of substitute

 

       grains that are gluten-free.

 

                 Many patients are quite willing to do that

 

       on their own.  Many of them use support group

 

       information where maybe a group has cooperatively

 

       contacted manufacturers who in good faith provide

 

       information on their source ingredients.

 

                 There are some patients who are entirely

 

       paranoid about it, and want to obtain a kit to test

 

       the food.  I don't know that we've got a very

 

       effective kit yet for testing food for gluten

 

       contamination.  There are many different attitudes.

 

                 Fear is a major concern among my patients.

                                                                 62

 

       I mean, fear of even the slightest potential, not

 

       even actual but potential contamination.  This can

 

       verge on, "Do we avoid taking prescription

 

       medications for things like hypertension?"

 

       resulting in life-threatening changes to their

 

       medication regimens because of fear of

 

       contamination.

 

                 I would say fear is a major part or a

 

       major influence on the quality of life.  We will

 

       hear more I think shortly on the impact of a

 

       gluten-free diet on patients' lifestyles a little

 

       later.  Certainly that does affect a substantial

 

       portion of my patients.

 

                 Patients go through a substantial grief

 

       reaction and feel socially isolated because of

 

       their difficulty of interacting with society,

 

       because so much of our society activities or social

 

       activities revolve around food.  There is that

 

       safety sense of insecurity, which I think pervades

 

       or affects many patients with celiac disease.

 

                 DR. BRILEY:  Thank you.

 

                 CHAIRMAN DURST:  Soheila.

                                                                 63

 

                 DR. MALEKI:  Well, I just want to know if

 

       there are any coordinated studies for a

 

       determination of thresholds?  I know you mentioned

 

       the level of PPMs.  Do you know of any studies?

 

                 DR. MURRAY:  There are and you will hear

 

       about them.  There are both retrospective and

 

       prospective studies, and you will be hearing some

 

       data on those later this morning.

 

                 CHAIRMAN DURST:  I have one question --

 

       Dick Durst -- on the biopsy and histological

 

       studies to see the morphology, morphological

 

       changes, you showed from the shag rug.  I am just

 

       curious whether just one of these cameras you can

 

       swallow would be able to detect those kind of

 

       changes without having to go through a biopsy?

 

                 DR. MURRAY:  Yes, you can detect them.

 

       Nobody would suggest that it would replace the need

 

       for biopsies to make the diagnosis.  There is

 

       really relatively little published data on it.

 

       There has been a paper suggesting that you can see

 

       those changes.  With a magnified view, you can see

 

       with a capsule.

                                                                 64

 

                 Yes, I think you can identify those

 

       changes in a lot of individuals with celiac

 

       disease, maybe all of them.  Although, I really

 

       can't comment more on that, because it hasn't

 

       really been studied in any great detail.

 

                 CHAIRMAN DURST:  Erica.

 

                 DR. BRITTAIN:  Erica Brittain.  Do you

 

       have any insight about the cumulative effect of

 

       decades of low levels, very, very low levels of

 

       gluten exposure?  Certainly, we are going to have

 

       to think about what chronic exposure could do when

 

       we talk about the thresholds.  Can you provide any

 

       insight into that?

 

                 DR. MURRAY:  Probably the best clinical

 

       insight I can give are individuals who I see who

 

       were diagnosed 20 years ago and have not come back

 

       to medical attention in 20 years.  I see those

 

       patients maybe every week.

 

                 I would see somebody who is diagnosed 20

 

       years ago, and they got instruction at that time

 

       that allowed them to eat things like barley malt or

 

       that people weren't really instructed about some of

                                                                 65

 

       those rice or corn cereals that may have contained

 

       malt, for example.

 

                 Those patients come back with anemia,

 

       chronic GI complaints, maybe not as severe as they

 

       had initially, but they certainly have accumulated

 

       some health morbidity over those 20 years.  Some of

 

       them will come back with frank lymphomas and will

 

       end up with a mortal complication of their celiac

 

       disease.

 

                 Yes, at least my clinical observation is

 

       that I frequently see individuals with problems

 

       that we get rid of, once they now move to a much

 

       more strict gluten-free diet, by eliminating those

 

       things -- largely, because in 20 years they didn't

 

       go back and get more education and realize that you

 

       had to exclude those minor ingredients.  That is

 

       one way of looking at the effects of decades'

 

       accumulation of low-level contamination.

 

                 CHAIRMAN DURST:  Dick Durst again.  On

 

       your slide that showed the various causes, the

 

       different grains, and so on, I believe you

 

       indicated oats was not one of the causes.  Could

                                                                 66

 

       you expand on that?

 

                 DR. MURRAY:  We will hear a little more, I

 

       think, from Dr. Collin on that issue.  While oats

 

       had been thought to be one of the offending grains

 

       in things done in the fifties and sixties, it turns

 

       out from recent very well-done studies that it

 

       doesn't appear to impair the healing of the

 

       intestine in newly diagnosed celiac disease.  It

 

       doesn't seem to result in a significant worsening

 

       of production of damage in patients who are already

 

       diagnosed with celiac disease.

 

                 For the vast majority of celiacs, it is

 

       probably safe in its native, pure form.  However,

 

       there are some sequences within oats that can

 

       produce an immune response, at least in vitro, in

 

       lymphocytes derived from a few celiacs.

 

                 It is not an absolute.  There may be some

 

       individuals with celiac disease that can respond to

 

       oats, both in the laboratory test and possibly also

 

       clinically there are a few.

 

                 There are probably a relatively small

 

       minority of celiacs in which that occurs.  A bigger

                                                                 67

 

       concern is the issue of contamination of oats with

 

       other grains that are well recognized to cause

 

       injury.

 

                 CHAIRMAN DURST:  Marc.

 

                 DR. SILVERSTEIN:  Marc Silverstein.  I

 

       would like to inquire about the potential

 

       subsequent lifelong increased risk of GI cancers.

 

       I presume that the risk is predominantly small

 

       bowel, but I wonder if there is any increased risk

 

       of colorectal cancer?

 

                 Then, what are your thoughts about whether

 

       there is sufficient risk that patients with celiac

 

       disease should be in some sort of surveillance

 

       program for early detection of GI cancer?

 

                 DR. MURRAY:  Clarifying the risk of

 

       cancers, it is particularly visceral cancer but

 

       also includes: esophageal cancer, non-Hodgkin's

 

       lymphoma of any site not just the intestine, and

 

       probably also B-cell lymphomas, as well as the

 

       T-cell lymphomas, small-bowel carcinoma.

 

                 There is a greatly increased relative risk

 

       of small-bowel carcinoma.  Of course small-bowel

                                                                 68

 

       carcinomas is a very rare disease to begin with, so

 

       the lifetime risk of dying of a small-bowel cancer,

 

       even in a celiacs, is still relatively small.  The

 

       data on colon cancer is mixed.  There is some that

 

       suggests there is an association; and some, that

 

       does not.

 

                 When you look at other causes of

 

       mortality, even non-cancer causes of mortality such

 

       as infections, neurologic disorders and chronic

 

       lung infections, there are other excesses of

 

       mortality that occur in patients with celiac

 

       disease.

 

                 There are some reductions in cancer

 

       mortality.  It appears, at least there is a

 

       suggestion, that breast cancer may be less common

 

       in celiac disease than non-celiac disease.  There

 

       were a couple of suggestions that lung cancer might

 

       be less common in celiac disease than in non-celiac

 

       disease.

 

 

                 Now, whether there is some competing issue

 

       like smoking may be less common in celiac disease

 

       than non-celiac disease, so there may be some other

                                                                 69

 

 

       competing issues that are involved.  Body size may

 

       make a difference.  It may be another confounding

 

       issue that confounds or is a competing risk for

 

       malignancies.

 

                 While small-bowel cancers and lymphomas

 

       are the two that have the greatest relative risk,

 

       it is a small, absolute risk because of the

 

       relative rarity of those cancers.

 

                 CHAIRMAN DURST:  Do we have any further

 

       questions for Dr. Murray?

 

                 (No verbal response.)

 

                 CHAIRMAN DURST:  Thank you very much.

 

                 Our next speaker is Cynthia Kupper, who is

 

       the executive director of the Gluten Intolerance

 

       Group of North America who will present on patient

 

       perspectives on celiac disease.

 

                  PATIENT PERSPECTIVES ON CELIAC DISEASE

 

                 MS. KUPPER:  Good morning.  I am a

 

       dietician, not a doctor.  I appreciate the honorary

 

       doctor status.

 

                 My job here today is to give a face for a

 

       person with celiac disease.  I have been tasked

                                                                 70

 

       with letting you know who they are, letting you

 

       know how they get their information and education,

 

       and then also providing you with some information

 

       about labeling that they have.

 

                 (Slide.)

 

                 MS. KUPPER:  First of all, living with

 

       celiac disease is very difficult.  It is a chronic,

 

       lifelong condition, as you have heard, and people

 

       find this to impact greatly their quality of life.

 

                 Forty-four percent of the patients in a

 

       Canadian study say that the diet is very difficult

 

       to follow.  In fact, there are some studies that

 

       suggest that the compliance with the diet can be as

 

       low as 50 percent in teenagers but probably ranges

 

       around 70 percent compliance.

 

                 Eighty-four percent of these patients in

 

       Canada suggested they have a difficult time

 

       determining what is gluten-free and what is not.

 

       They don't travel, and they don't eat out.  It

 

       impacts their family life and their career.

 

                 If you have celiac disease and are an

 

       X-ray technician, oftentimes you change careers

                                                                 71

 

       because sometimes the X-ray slides are dusted with

 

       flour.  Chronic exposure could impact your quality

 

       of life.

 

                 (Slide.)

 

                 MS. KUPPER:  I did a study online of 620

 

       patients a few months ago.  In response to that

 

       study, 75 percent of them said that they can tell

 

       the difference between a gluten reaction and other

 

       intolerance or a food allergy.

 

                 When they discussed their reaction

 

       symptoms, they ranged from anaphylaxis, which is

 

       not a gluten reaction for celiac disease, to

 

       delayed reactions which could impact any aspect of

 

       their GI and other health systems, body systems.

 

                 The average time to reaction was somewhere

 

       between four to eight hours, but some of them

 

       complained of immediate, almost allergic type

 

       responses, and many of them said that their

 

       responses or the symptoms that they had would last

 

       for several days.

 

                 Keep in mind, there is no medication we

 

       can give them to make this go away, so they just

                                                                 72

 

       have to let it work its course.  This is really

 

       disturbing to me.

 

                 (Slide.)

 

                 MS. KUPPER:  As a dietitian, patients do

 

       not rely on medical communities and professionals

 

       for their information.  They rely primarily on

 

       support groups.

 

                 Actually, the Internet should probably be

 

       the first one, because they are Internet savvy.

 

       They have been out there and they have gotten all

 

       kinds of information before they ever see a

 

       dietitian.  Not only do they get information from

 

       the Internet and the support groups, but there are

 

       list serves and chat groups that they belong to.

 

                 These can be very useful tools for a

 

       person with celiac disease.  However, they also

 

       provide some very frightening and unreliable

 

       information that the patients will hold onto as if

 

       it were gospel.  Then, they work with self-help

 

       books as well.

 

                 Unfortunately, doctors, and especially

 

       dietitians, are seen as unreliable.  It is sad for

                                                                 73

 

       me to say that as a dietitian my profession doesn't

 

       get this disease.  They also treat it like it is a

 

       rare thing, and they don't know anything about it.

 

       In the United States, I can tell you that there is

 

       probably a handful of dietitians who would be

 

       considered experts in celiac disease.

 

 

                 Doctors don't get much more respect,

 

       primarily because it has taken so long for the

 

       patient to get a diagnosis that the patient has

 

       lost faith.

 

                 Then, they will go to research facilities

 

 

       like the University of Maryland, Chicago, and

 

       New York, or the Mayo Clinic.  Lastly, they will go

 

       to medical Web sites.  The bulk of our information

 

       is coming from potentially unreliable and

 

       non-research-based sites.

 

                 (Slide.)

 

                 MS. KUPPER:  The consumers perceive that

 

       gluten exposure levels -- the question was asked to

 

       me, "What do consumers believe about gluten

 

       exposure?  Are they concerned about the health

 

       risks?"  The answer is yes and no.

                                                                 74

 

                 On the study that I did, it depended upon

 

       their confidence of the labeling, and it depended

 

 

       on whether they accepted testimony or accepted

 

       research.  There is a group of celiacs, as

 

       Dr. Murray suggested, who really don't want to

 

       listen to what research suggests.

 

                 As you move forward, with not only

 

       establishing how you are going to determine the

 

       threshold but what that threshold will be, you will

 

       have a fight in the celiac community for a lack of

 

       education and understanding of research.

 

                 Consumers oftentimes also have an

 

       inability to correctly interpret research findings.

 

       These are people who have just enough medical

 

       knowledge to be dangerous, so they don't have a

 

       full understanding of the terminology they are

 

       talking about.

 

                 There is this constant perpetuation of

 

       misinformation.  I don't know how many times when

 

       we try to bury something that is inaccurate it gets

 

       dug up.

 

                 (Slide.)

                                                                 75

 

                 MS. KUPPER:  There are varying levels of

 

       gluten sensitivity, as you heard, too.  There is

 

       the perception that gluten is poison.  Not unlike

 

       the allergy people that we heard from yesterday,

 

       this is a huge issue to the celiac consumer.

 

                 They believe most of the time that when

 

       their gut hurts it is from gluten not from

 

       something else.  Consequently, we are trying to

 

       help the patient understand that not everything

 

       that makes their gut hurt is gluten.

 

                 As Dr. Murray said, there is a huge fear

 

       reaction.  If I had to put a psychological label to

 

       a group or at least a portion of the celiac

 

       community, they are filled with fear and a little

 

       bit paranoid about what they can and can't do.

 

                 How do we define "gluten-free" in the

 

       U.S.?  This is a really interesting question.  Of

 

       the consumers, only 19 percent realize that there

 

       is no definition right now for gluten-free in the

 

       U.S.  Many of them define that the true definition

 

       is zero.  This is a problem -- a lot don't know.

 

                 (Slide.)

                                                                 76

 

                 MS. KUPPER:  When I ask the question, "Do

 

       you trust gluten-free labeling?"  It was

 

       interesting, too, because most of the people say

 

       they do trust it.  However, when you ask them if

 

       they ever had a reaction to a product labeled

 

       gluten-free, you can see that up to 50 percent

 

       suggested that they might have had a reaction to a

 

       gluten-free product.

 

                 When I talk to manufacturers that

 

       manufacture only gluten-free products and ask them,

 

       "Do you test, and what do you test to," many of

 

       them are using older testing methods not the newer

 

       testing methods, the monoclonal tests that we

 

       talked about yesterday.

 

                 Some of them tested 200 parts per million,

 

       some of them tested 20 parts per million, some of

 

       them tested no detectible.  For the gluten-free

 

       consumer today, the label "gluten-free" really has

 

       no meaning.

 

                 (Slide.)

 

                 MS. KUPPER:  Again, the gluten-free

 

       consumer is compulsive about their medical needs. 

                                                                 77

 

       This is their only treatment.  It is often referred

 

       to as our drug of choice.  There is nothing else we

 

       can do, except to follow a strict gluten-free diet.

 

                 They have very limited trust in the

 

       manufacturing industry.  They believe that labels

 

       that say "may contain" and different things like

 

       that need to be distrusted.  When they call the

 

       manufacturers, they are not quite sure that they

 

       are getting the right answer all the time.

 

                 Also, they have a limited understanding of

 

       what good manufacturing practices really mean, so

 

       they are always questioning what the manufacturer

 

       will say.  Yet, at the same time they want

 

       accountability and they want reliability.

 

                 They may translate information to the

 

       extreme.  Let me give you an example.  A few months

 

       ago on one of the list serves, someone put out a

 

       message about bottled water being gluten-free.

 

                 That got taken in a week's time to the

 

       point where consumers were calling asking why water

 

       had gluten in it, and how dare the food industry do

 

       that to them.  The reality is it never did.

                                                                 78

 

                 A company, out of the graciousness of

 

       their heart, put it on a list of gluten-free

 

       products, and from that the consumer decided that

 

       every other bottled water had gluten in it.  This

 

       is the extreme that the consumer can go to.  Again,

 

       they don't find descriptive labeling helpful at

 

       all.

 

                 The changes that can occur in ingredients

 

       in manufacturing processes make it difficult for

 

       this consumer group to know what they can have.

 

       The term "modified food starch" usually means

 

       cornstarch, modified cornstarch, in this country.

 

                 However, if the manufacturer determines

 

       that wheat starch is cheaper in the fall and they

 

       switch and the consumer has determined that this

 

       product is gluten-free, now they are in trouble if

 

       they don't recheck.

 

                 When you talk to the food industry, you

 

       will find that their calls have dramatically

 

       increased over the last 2 to 5 years of consumers

 

       calling in, and 90 percent of the questions do not

 

       have to do with other allergens but have to do with

                                                                 79

 

       gluten.

 

                 (Slide.)

 

                 MS. KUPPER:  When the consumer asks the

 

       question about gluten, the problem is that they are

 

       asking the wrong question.  The consumers believe

 

       that if they don't have effective labeling how can

 

       anybody possibly know that they are going to be

 

       able to be healthy and protect themselves.

 

                 They want to know that if you call a

 

       company they are really giving you the right

 

       answer, and they are just never confident about

 

       that.  Oftentimes, when the company answers too

 

       quickly, they get suspicious.

 

                 Oh, I've had that experience.  I will call

 

       on a product and I'll say, "I need to know the

 

       source of the modified food starch."

 

                 "Oh, you're talking about gluten?"

 

                 "Yes.  Tell me the source of your modified

 

       food starch.  Let me make that decision about

 

       whether I'm talking about gluten."  That makes a

 

       consumer suspicious.

 

                 Finally, you know, if a person eats a

                                                                 80

 

       gluten-free food and they get sick, whether it is

 

       related to gluten ingestion or not, they have

 

       determined that they can't trust that company any

 

       longer.

 

                 Again, these list serves and chat groups,

 

       I have seen them take small companies out of

 

       business because of the spreading of rumors --

 

       which are probably unfounded.

 

                 (Slide.)

 

                 MS. KUPPER:  In closing thoughts, I really

 

       encourage that through this entire process related

 

       to labeling thresholds, that we be talking a common

 

       language.

 

                 Let me use the example of threshold.

 

       Yesterday, as I listened to Anne Munoz talk about

 

       thresholds for allergens, I realized that we have

 

       three different definitions of thresholds -- or

 

       tolerance, excuse me.  I want to use the word

 

       tolerance.

 

                 The consumer says, "Tolerance is zero."

 

       What that means is they think there should be zero

 

       gluten in their food.

                                                                 81

 

                 The medical community says "zero

 

       tolerance."  For them that means, you should be on

 

       a strict diet, and you should never cheat.

 

                 The manufacturing industry wants to know

 

       where that is.  Is it 20?  Is it 200?  They know it

 

       is not zero.

 

                 We are not talking the same language.  The

 

       consumer needs to know that the manufacturer and

 

       the industry or the legal ramifications around any

 

       labeling are all using common terminology in a

 

       language they can understand.

 

                 Education is a huge component.  As much as

 

       I am a supporter of this regulation and this law,

 

       one of the things that is going to happen, as you

 

       heard yesterday in discussions about soy lecithin

 

       and other ingredients, it is going to become a bag

 

       of worms.  For the consumer, it is going to be very

 

       confusing, and we need to have an education

 

       component as part of the new labeling laws.

 

                 I encourage you, too, although you heard

 

       it yesterday and you will probably hear it today,

 

       too, we know that there is no testing kit available

                                                                 82

 

       that tests to zero.  We know, as you will probably

 

       hear later, that it is probably an impracticality

 

       or unnecessary to even go there.

 

                 I implore that when you set a threshold

 

       method and testing methods, when you set the

 

       threshold level, that it be reasonable and

 

       something that meets the health needs of the

 

       consumer but also allows the industry to meet the

 

       need.

 

                 (Slide.)

 

                 MS. KUPPER:  As they found out in

 

       Australia, when you set zero as the tolerance level

 

       and as the magic number for food manufacturers, a

 

       lot of gluten-free products that patients used no

 

       longer can be labeled gluten-free.  Now the

 

       consumer is once again confused and outraged.

 

                 CHAIRMAN DURST:  Thank you very much.

 

                 Do we have any questions for our speaker?

 

                 Yes, Jeff?

 

                 DR. BARACH:  Hi.  Thank you.  Jeff Barach

 

       with Food Products Association.  If I interpret

 

       what you said correctly, you were talking about the

                                                                 83

 

       consumer really doesn't find descriptive labeling

 

       very helpful in the case of gluten-free.

 

                 I assume then the consumer would go to the

 

       ingredient list or the 800 numbers or their

 

       internal chat groups to find out whether the

 

       product really is gluten-free or not.  Am I

 

       interpreting that right?  Your constituency does

 

       not want gluten-free labeling?

 

                 MS. KUPPER:  I would say that is probably

 

       right, that is the message I got from the survey.

 

       In fact, they found that labels that say "may

 

       contain" or "processed in a plant with" really is

 

       frightening to them.  They will look at a product

 

       like that, and they will simply avoid it.

 

                 They do go to chat rooms and there are

 

       lists of gluten-free products.  However, when you

 

       look at those lists and you ask how they were

 

       developed, there are no standards for developing

 

       those lists.

 

                 DR. HEIMBURGER:  Doug Heimburger, a follow

 

       up to that.  That is not the same, is it, as saying

 

       "gluten-free"?  Do they not want a label except it

                                                                 84

 

       is gluten-free with a consistent and clear

 

       definition of that?

 

                 MS. KUPPER:  They do want a label that

 

       says gluten-free with a clear and consistent

 

       definition.

 

                 DR. HEIMBURGER:  Yes.

 

                 MS. KUPPER:  I believe that gluten-free is

 

       not is not going to mean zero; it can't mean zero.

 

                 CHAIRMAN DURST:  Any further questions or

 

 

       comments?

 

                 (No verbal response.)

 

                 CHAIRMAN DURST:  Thank you very much.

 

                 CHAIRMAN DURST:  Our next speaker is

 

       Dr. Donald Kasarda, who is a consultant and retired

 

       senior scientist from the Agricultural Research

 

       Service of the USDA.  He will make a presentation

 

       on grains.

 

                                  GRAINS

 

                 DR. KASARDA:  Good morning everyone.  I am

 

       a research chemist retired from the U.S. Department

 

       of Agriculture, although I still maintain a

 

       relationship with my old lab in Albany, California,

                                                                 85

 

       as a collaborator.

 

                 Now, Dr. Murray covered a lot of the

 

       things I am going to talk about.  Maybe I will be

 

       able to add a little bit more detail to some of

 

       them, but he did an excellent job of talking about

 

       some of the grain topics.

 

                 (Slide.)

 

                 DR. KASARDA:  Immunology textbooks often

 

       classify hypersensitivities into these four types.

 

       Celiac disease is a delayed type hypersensitivity

 

       that involves T-cells in the primary mechanism.  It

 

       falls into Type IV.  Allergy is Type I and is

 

       mediated by IgE antibodies.

 

                 Now, in the case of celiac disease, it is

 

       often suggested that there is a Th1 mechanism

 

       involved in which T-cells are presented with

 

       gliadin peptides, and, ultimately produce

 

       cytokines, inflammatory cytokines such as

 

       interferon gammas as an example.

 

                 Now, in the case of allergy, however, the

 

       same molecules that can induce the symptoms of

 

       celiac disease are also capable of producing

                                                                 86

 

       allergies.  We do have a certain amount of

 

       confusion sometimes between immediate

 

       hypersensitivities and the delayed-type, celiac

 

       disease.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, this is the same

 

       diagram that Dr. Murray showed.  I want to talk

 

       about primarily the endosperm, which is this white

 

       part here (indicating) in the cutaway diagram.

 

                 The starchy endosperm is made up of about

 

       75 percent starch, but it also contains about 7 to

 

       17 percent protein, depending on the use of the

 

       wheat.  Most of this protein, about 75 percent of

 

       it, is gluten protein.

 

                 The proteins are storage proteins.  They

 

       are used by the developing plant that comes from

 

       the germ here.  The germ is separated from the

 

       outer layers and the endosperm during the milling

 

       process after crushing and sieving.

 

                 The storage proteins are broken down upon

 

       germination of the seed to produce a new plant.

 

       The resulting amino acids and nitrogen are used in

                                                                 87

 

       the synthesis of new molecules needed by the

 

       developing plant.  Now, as I mentioned, about 75

 

       percent of the storage protein is, in fact, gluten

 

       protein.

 

                 (Slide.)

 

                 DR. KASARDA:  This is a picture of flour

 

       particles, a scanning electron micrograph.  These

 

       round, spherical structures are starch granules.

 

       These (indicating) are A type, there are some

 

       B types which are small here.  The surrounding

 

       rough-edged material is the gluten protein or

 

       storage protein.

 

                 (Slide.)

 

                 DR. KASARDA:  If you mix together flour

 

       and water, as most of you have had the experience,

 

       you can form a cohesive elastic dough.  If you need

 

       a dough under water, say, in a large container of

 

       water or under a stream of water, you can wash out

 

       the starch granules; they pop right out of the

 

       matrix.  You are left with a cohesive, elastic mask

 

       consisting mainly of the storage or gluten

 

       proteins.

                                                                 88

 

                 (Slide.)

 

                 DR. KASARDA:  Now, this is the traditional

 

       cereal chemist definition of gluten.  You cannot

 

       carry out this process with rye and barley.

 

       Therefore, to the traditional cereal chemist, there

 

       is no gluten in rye and barley.  However, the

 

       celiac disease community has adopted the term

 

       "gluten" for any protein that is toxic or harmful

 

       to a celiac patient.

 

                 This terminology problem sometimes is

 

       confusing when patients go to a company where they

 

       might be dealing with a traditional cereal chemist,

 

       and there is a certain amount of confusion as to

 

 

       what is gluten.  As I said, this is the traditional

 

       definition, but it has been expanded to include

 

       other grains that are harmful to celiac patients.

 

                 Now, from time to time, you will hear

 

       about these fractions of gluten.  Going way back,

 

       at least over a hundred years, it has been

 

       traditional to divide gluten into two, roughly,

 

       equal fractions based on their solubility.  This is

 

       not an exact separation.  No solubility fraction is

                                                                 89

 

       ever perfect.

 

                 Traditionally, it was alcohol-water

 

       solution and sometimes we used detergent solutions.

 

       We divide it up into the soluble fraction, which we

 

       call "gliadin."

 

                 This is made up of monomeric proteins of

 

       the prolamin class.  The prolamin terminology comes

 

       from Osbourne back around 1900.  It is derived from

 

       the fact that there are two major amino acids found

 

       in the composition of these proteins.  Proline and

 

       glutamine, hence, prolamin.

 

                 By structure, we have three types: the

 

       alpha type, gamma type, or omega types.  Sometimes

 

       people speak of the alpha/beta.  I will talk about

 

       that in a little as we go along.

 

                 Now, the insoluble fraction is called

 

       "glutenin" by the cereal chemists.  In rye and

 

       barley, there is an equivalent fraction that we

 

       called just generically "glutelin."

 

                 Now, this polymeric fraction consists of

 

       prolamin subunits.  Again, large amounts of proline

 

       and glutamine in the composition of the proteins. 

                                                                 90

 

       These subunits are linked together by disulfide

 

       bonds into a higher level of polymer.

 

                 Of course, a protein is a polymer in

 

       itself.  It is divided into two main types the

 

       low-molecular weight and the high-molecular weight

 

       glutenin subunits.

 

                 (Slide.)

 

                 DR. KASARDA:  This just is a table showing

 

       the percentages in the various types of proteins.

 

       For example, you have the sum of glutamine and

 

       proline ranging from about 40 percent up to about

 

       80 percent in some of the omega gliadins.

 

                 This is pretty unusual to have such a high

 

       percentage of glutamine and proline.  This is key

 

       to the toxicity, because the toxic sequences

 

       involve glutamine and proline and usually an

 

       aromatic as well, either tyrosine or phenylalanine.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, the terminologies that

 

       we use really go back to early electrophoretic

 

       studies in the late sixties and early seventies.

 

       Again, if we follow this diagram here, this is an

                                                                 91

 

       acid gel in which the proteins are separated by an

 

       electric field in a polyacrylamide gel.

 

                 The terminology actually came from a sort

 

       of free-boundary electrophoresis that was carried

 

       out at our Northern Regional Research Center back

 

       in the sixties.  When they developed the

 

       polyacrylamide gel electrophoresis, it was found

 

       that the fractions fit with the mobility in the

 

       electrophoretic gel.

 

                 You have the alpha, fastest moving; beta;

 

       gamma; and omega.  Structurally, the alphas and

 

       betas are pretty similar.  Some people will talk

 

       about alpha/beta types.  I just lump them together

 

       as alpha types.

 

                 Now, the alpha type and gamma type are

 

       about the same size.  If you carry out SDS page or

 

       polyacrylamide gel electrophoresis in detergent,

 

       sodium dodecyl sulfate, which is a very good

 

       dissociating agent for proteins.

 

                 Reduced or unreduced the gliadins give a

 

       pattern somewhat similar to this.  It is not quite

 

       as good at resolving alpha, beta and gammas as you

                                                                 92

 

       find in the acid gels where aluminum lactate was

 

       one of the favorite buffers.

 

                 If we go over to the glutenin fraction,

 

       and these are the subunits linked together by

 

       disulfide bonds, if you try to take a purified

 

       glutenin fraction and run it into an acid gel or

 

       into a detergent gel, mostly you've just got a

 

       little bit of streaking around the origin because

 

       the polymers are too large to migrate into the gel.

 

                 (Slide.)

 

                 DR. KASARDA:  Upon reduction, however, you

 

       begin to see this type of pattern here in which

 

       there is a group of high-molecular-weight subunits

 

       and a group of low-molecular-weight subunits.  This

 

       only occurs for the glutenin fraction when you

 

       reduce the disulfide bond.

 

                 (Slide.)

 

                 DR. KASARDA:  This is a two-dimensional

 

       pattern, electrophoretic pattern, of the gluten

 

       proteins.  All you have to recognize is that each

 

       spot here represents a separated protein.  There

 

       are quite a few different gluten proteins, and we

                                                                 93

 

       can count easily 50, 60, 70 spots in such a

 

       pattern.  Therefore, there are at least 50, 60, 70

 

       gluten protein components.

 

                 We know from genomic studies that, in

 

       fact, there are probably at least a hundred genes

 

       coding for these proteins, and probably several

 

       hundred genes coding for the proteins.  The loci in

 

       the genome that code for these proteins are spread

 

       out over about nine different loci in the genome.

 

                 Now, as far as we know, all of these

 

       gluten proteins are toxic in celiac disease.  This

 

       group here (indicating) are the omega gliadins, and

 

       they seem to be particularly active.

 

                 However, all of the gluten proteins have

 

       been tested by Paul Ciclitira's group and

 

       Peter Howdle's group in the U.K., and they all

 

       indicated by direct installation into the small

 

       intestine that these proteins, all of these

 

       different classes are toxic.

 

                 These omega gliadins are noted for being

 

       strong allergen in exercise-induced anaphylaxis.

 

       They are one of the really strong antigens involved

                                                                 94

 

       in that particular allergy.

 

                 (Slide.)

 

                 DR. KASARDA:  This is a schematic diagram

 

       that illustrates the fact that all of these

 

       proteins are noted for a repetitive domain in which

 

       certain amino acid sequences are repeated over and

 

       over again.

 

                 They are somewhat degenerate, but we can

 

       derive consensus sequences.  These are glutenin

 

       subunits, gamma-type gliadins.  These red,

 

       staplelike lines indicate intramolecular disulfide

 

       bonds.

 

                 In a glutenin subunit, we also have free

 

       cysteines which can link up to another molecule to

 

       form these higher-level polymers.  For example,

 

       here is an alpha-gliadin -- I'm going to talk about

 

       this a little bit more -- the end terminal, or the

 

       first half of the molecule, is made up of these

 

       repeating sequences.

 

                 The second half is not repetitive and

 

       contains most of the disulfide bonds.  Toxicity

 

       seems pretty likely to be limited to the repeat

                                                                 95

 

       regions.  These are the high-glutamine, the

 

       high-proline regions.

 

                 Now, the omega-type gliadin seems to have

 

       lost -- well, we are not entirely sure whether they

 

       lost this type of domain or not, but in any case

 

       they are made up almost entirely of repeating

 

       sequences.

 

                 (Slide.)

 

                 DR. KASARDA:  This is a hypothetical model

 

       of the gluten polymer or glutenin in which the

 

       subunits are joined by intermolecular disulfide

 

       bonds, there are also these intramolecular

 

       disulfide bonds, to form a higher-level polymer

 

       that provides elasticity to a dough.

 

                 The gliadins and the glutenins are

 

       cohesive with one another, but the gliadins

 

       contribute more to the extensibility of the dough,

 

       and the elasticity comes primarily from the

 

       glutenin fraction.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, here I show some of the

 

       types of sequences that you find in the repeats. 

                                                                 96

 

       Now, they look pretty similar, a lot of glutamine,

 

       which is represented by "Q"; a lot of proline

 

       represented by "P"; and usually an aromatic

 

       residue, either phenylalanine, "F," or tyrosine,

 

       "Y."

 

                 Somewhere, and these are often degenerate.

 

       They are not exactly according to the consensus

 

       that I show here.  Somehow along the line these

 

       sequences have acquired toxicity in celiac disease.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, this is the complete

 

       sequence of an alpha gliadin.  This is the

 

       end-terminal region up here (pointing).  It starts

 

       at one, and there are 263 amino acid residues.

 

       Here, note the predominance of the blue Q's and the

 

       red P's for the proline and glutamine residues.

 

                 This half of the molecule here is the

 

       repeat region.  There is also this interesting set

 

       of glutamines, which really hasn't been studied in

 

       celiac disease.  It is probably not toxic, but, as

 

       I say, there has been almost no study of this

 

       polyglutamine stretch here.

                                                                 97

 

                 Note also these vertical lines here which

 

 

       I show.  Those are sites that we have observed

 

       where cleavages occur with gastric enzyme, pepsin

 

       and pancreatic enzymes, trypsin and chymotripsin.

 

                 Now, most proteins would be broken down by

 

       the digestive enzymes into single amino acids or

 

       very small peptides: diatride, tetrapeptides that

 

       are easily absorbed, which are probably not toxic.

 

                 (Slide.)

 

                 DR. KASARDA:  In the case, as Dr. Murray

 

       mentioned, because we have a lot of proline which

 

       interferes with the breakdown by the proteolytic

 

       enzymes, we can get some pretty large stretches.

 

       This stretch here from 31 to 55 right here is

 

       something that we have tested as toxic.

 

                 Other people have dealt with sequences

 

       from this stretch and found them also to be at

 

       given toxic.  The fact that this gliadin and

 

       glutenin proteins are difficult to digest by the

 

 

       digestive enzymes allows these toxic stretches to

 

       exist longer than you would find for other

 

       proteins.

                                                                 98

 

                 Now, this half of the molecule has a fair

 

       amount of glutamine and proline, but as far as we

 

       know toxicity does not reside in this C-terminal

 

       half or sort of the end of the molecule.  It is in

 

       sort of the forward end of the molecule.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, this is what I would

 

       call my string of beads model in which I have just

 

       taken that sequence, 1 to 263, and shown it as

 

       beads on a string.

 

                 Each bead represents a different amino

 

       acid.  I tried to assign the different amino acids

 

       different code words to distinguish them.  This is

 

       the end terminal region of repeats.  This

 

       C-terminal where we have the disulfide bonds here.

 

       Toxicity resides in this part here.

 

                 This sequence here from 31 to 43 was

 

       synthesized by Mike Marsh in the U.K. first, and he

 

       instilled the synthetic peptide directly into the

 

       small intestine of several celiac patients and

 

       found changes in the mucosa that were indicative of

 

       celiac disease.  So this does seem to be a toxic

                                                                 99

 

       sequence.

 

                 Here I show a computer molecular model of

 

       what that sequence would look like in the

 

       polyproline II left-handed helical confirmation

 

       that Dr. Murray mentioned.  We think that these

 

       peptides do have a strong tendency to assume this

 

       polyproline II confirmation.

 

                 Here, I show the sequence in three-letter

 

       code as a string of beads model and here just a

 

       single-letter code.  I know most people are not

 

       used to dealing with these codes.  I apologize for

 

       using them in some of the slides, but often I am

 

       just trying to make a general point, and you don't

 

       really have to follow the sequences according to

 

       their exact correlations with the amino acids.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, this is a list of some

 

       of the either toxic or immunoactive peptides that

 

       have been described in the literature.  This is

 

       from Sean, et al, from Chaitan Khosla's lab at

 

       Stanford.  The 33-Mer appears to be a very active

 

       sequence.  I have indicated some sort of homology

                                                                100

 

       here by the yellow boxes here.

 

                 All of these sequences, with the exception

 

       of this one, have been found to be toxic by direct

 

       installation into the small intestine or they have

 

       been found to stimulate T-cells, T-cell clones,

 

       derived from biopsies of celiac patients.

 

                 These are just some of the toxic

 

       sequences.  We don't know all of the toxic

 

       sequences at this point.  There are certainly

 

       others to be found, so it is a pretty complicated

 

       situation in trying to sort out exactly what it is

 

       about the sequences that produces toxicity in

 

       celiac disease.

 

 

 

                 (Slide.)

 

                 DR. KASARDA:  Now I want to move on and

 

       talk a little bit about the other grains.  If we

 

       start with the class flowering plants, which is one

 

       of the major divisions or plants in terms of

 

       taxonomy.

 

                 We go down to the major two subclasses,

 

       monocotyledones plants and dicotyledones plants. 

                                                                101

 

       We can follow the monocots down to the Gramineae or

 

       the grass family.

 

                 Here, we have only wheat, rye and barley

 

       that are toxic.  Triticale is a cross between wheat

 

       and rye, and so would be expected to be toxic.

 

                 Now, oats I have had to put in both

 

       columns, and I will explain why.  There are many

 

       other grasses in which the grains do not have toxic

 

       proteins as far as we know.

 

                 There are only two grains that have been

 

       studied with modern methods and modern approaches

 

       to understanding their relationship to celiac

 

       disease, and that is wheat and oats.

 

                 These others have often been studied very

 

       minimally including rye and barley, but rye and

 

       barley do contain proteins that have sequences

 

       quite close to those in wheat.

 

                 We assume that rye and barley are probably

 

       toxic grains according to the early results of

 

       Dicke in the Netherlands back around 1950, where

 

       they considered rye, barley and oats as part of the

 

       toxic group.

                                                                102

 

                 Now about 15 years ago, I suggested that

 

       if there are only a few grasses that contain the

 

       toxic sequences, and they are closely related as

 

       you will see, and then there are many other grasses

 

       that do not contain the toxic sequences.

 

                 I suggested that if you get into the dicot

 

       group -- the buckwheat, quinoa, amaranth, and these

 

       other grains -- it would not be toxic, simply

 

       because of their distant taxonomic relationship to

 

       wheat.

 

                 I was a little bit apprehensive about

 

       suggesting this, but over the past 15 years since I

 

       suggested this, people have been eating these other

 

       grains.  As far as I know, there hasn't been any

 

       serious indication that these do, in fact, have

 

       toxicity for celiac patients.

 

                 There have been some very fine studies

 

       from Finland and throughout the world, indicating

 

       that oats were safe for celiac patients.  But

 

       towards the end of last year the Oslo, Norway,

 

       group under Knut Lundin and Ludvig Sollid.  They

 

       have found -- well, I'm getting a little bit ahead

                                                                103

 

       of myself.  Let's deal with this slide first.

 

                 (Slide.)

 

                 DR. KASARDA:  If we take a subfamily,

 

       festucoidiae, of the grass family and we look at

 

       the tribal level, and I made this slide before the

 

       results from Oslo were published.  The hordeae --

 

       which includes wheat, rye, and barley -- were one

 

       tribe.  I thought that oats were probably

 

       non-toxic, so I put them in -- well, they belong in

 

       a separate tribe.  It was only this one tribe that

 

       had the toxic sequences.

 

                 Now, it is pretty certain that the oats

 

       are toxic to a few probably rare individuals, but

 

       we don't really know how this works out.  They

 

       found three celiac patients who definitely reacted

 

       to oats by the same mechanism that they reacted to

 

       gliadin peptides.  This, I think, was pretty well

 

       demonstrated by the work from Norway.

 

                 Now, here I show the proteins that you

 

       find in wheat, gamma-type gliadins and related

 

       low-molecular-weight glutenin subunits, they are

 

       found in rye, barley, not in oats.  Alpha-type

                                                                104

 

       gliadins are found in wheat, but you don't find

 

       them in rye and barley or in oats, and so on down

 

       the line.

 

                 Now, the avenins are a small fraction of

 

       the total proteins in oats.  These make up only

 

       about 10 percent of the protein.  Most of the

 

       protein is oat globulin, which as far as we know if

 

       not harmful or toxic to celiac patients.  There are

 

       low-molecular weight proteins related to the

 

       avenins in rye, barley, and wheat.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, this is another one of

 

       those sequence slides, but let me just try to make

 

       a few points here.  This top sequence is a gliadin

 

       sequence.  It starts here (indicating) and runs

 

       down to here.

 

                 The bottom sequence is an avenin, which

 

       shows a lot of homology with the C-terminal half of

 

       this gamma-gliadin molecule.  This is also true for

 

       the alpha gliadins.  Where the amino acids are the

 

       same, I have colored them in blue.

 

                 There is a lot of homology here in the

                                                                105

 

       C-terminal half, but that is not where the toxicity

 

       lies.  The Oslo group has shown that this

 

       particular sequence, which I have underlined, does

 

       have certain characteristics including glutamic

 

       acid at key positions that are important, as Dr.

 

       Murray pointed out, for binding to MHC proteins.

 

                 Consequently, most of the repeat region is

 

       absent from the avenins.  There is just this sort

 

       of residual section here, which does have a lot of

 

       glutamine and a lot of proline and some key

 

       glutamic acid sequences or amino acids that seem to

 

       be responsible in these few patients that have been

 

       studied for the toxicity.  This sequence is

 

       certainly capable of stimulating T-cell clones from

 

       these patients.

 

                 I think that the evidence is pretty good

 

       that there are at least a few -- it seems as though

 

       there are probably rare individuals who respond to

 

       oats and probably most celiac patients do not

 

       respond to oats.

 

                 This is a rather puzzling situation,

 

       because I have always thought of the proteins as

                                                                106

 

       being pretty definitive for celiac disease, that

 

       all celiac patients reacted to wheat and probably

 

       to rye and barley, and that this was part of the

 

       definition of celiac disease.

 

                 Now we have a situation here where it

 

       appears that some patients react to oats and some

 

       don't.  This is some ongoing research that needs

 

       some elucidation.

 

                 (Slide.)

 

                 DR. KASARDA:  Just to jump back into the

 

       classification, this is another subfamily,

 

       panacoideae.  Here we have maize and sorghum and

 

       millet.  We have actually done a little bit of

 

       end-terminal sequencing on sorghum and millet

 

       proteins, and they do seem fairly close to the maze

 

       protein.  This would explain to some degree why

 

       they are not toxic in celiac disease.  As far as we

 

       know, it is still wheat, rye, and barley that are

 

       harmful.

 

                 (Slide.)

 

                 DR. KASARDA:  Now, this is my last slide.

 

       The currently favored method for determination of

                                                                107

 

       gluten in food is the R5 monoclonal antibody ELISA

 

       test developed by Mendez in Spain.  This seems to

 

       be a pretty good test; it is not perfect.

 

                 The antibody reacts to monomeric wheat,

 

       rye and barley prolamins, but not the oat avenins,

 

       and it reacts weakly or not at all with the

 

       glutenin or glutelin, pretty good sensitivity,

 

       recognizes these particular motifs more strongly,

 

       although some others that are similar are

 

       recognized weakly.

 

                 The Codex Committee on Methods agreed in

 

       2004 to endorse temporarily the R5 ELISA for the

 

       determination of gluten.  Now, there are some

 

       possible problems.  There is the failure to detect

 

       the glutenin proteins.

 

                 In some preliminary work from our

 

       laboratory, for example, when we look at wheat

 

       starch that is intended for use by celiac patients,

 

       we find that the gliadins are pretty well washed

 

       out, but we do find evidence of

 

       high-molecular-weight glutenin subunits attached to

 

       the starch surface.  These would not be picked up

                                                                108

 

       by the R5 ELISA.

 

                 Then, there is the question about small

 

       peptides from hydrolases.  There has been some work

 

       described using a competitive assay, which might

 

       possibly solve the problem of the small peptides

 

       from hydrolases.

 

                 Also, there is a certain amount of data

 

       indicating differences in the results from

 

       different labs on the same sample.  On the whole,

 

       it seems like a pretty good test that can be used.

 

       As I say, it is not perfect, but it is a pretty

 

       impressive test on the whole, and it may be as

 

       close as we are going to get.

 

                 Although, I certainly can think of some

 

       ideas for maybe improving it.  At any case I think

 

       I will end my talk here and I thank you very much

 

       for your attention.

 

                 CHAIRMAN DURST:  Thank you.

 

                       QUESTION AND ANSWER SESSION

 

                 CHAIRMAN DURST:  Are there questions?

 

                 Okay.  Margaret?

 

                 DR. BRILEY:  Margaret Briley.  Can you

                                                                109

 

       give us any idea of the use of this ELISA test by

 

       industry in terms of the frequency and the

 

       acceptance and willingness to do it?  Do you have

 

       any feel for that?

 

                 DR. KASARDA:  Well, I think it is being

 

       used, and Dr. Collin can comment on this,

 

       extensively used in Europe and it is becoming used

 

       in the U.S.  Susan Hefle, who spoke yesterday, I

 

       think that they have done a certain amount of work

 

       using this test for industry.

 

                 My impression is that not much testing is

 

       done in the U.S.  Maybe Cynthia could comment on

 

       that.  I think it is developing, but we are quite a

 

       bit behind the Europeans in terms of a willingness

 

       to test and desire to test products and make sure

 

       that they are as close to gluten-free as they

 

       possibly get.  I can't give you a definitive

 

       comment on that.  I haven't made any surveys.

 

                 CHAIRMAN DURST:  Any further questions or

 

       discussion?

 

                 Yes?

 

                 DR. CALLERY:  Pat Callery.  Thank you for

                                                                110

 

       the review of the relevant biochemistry.  Could you

 

       relate the transglutaminase substrate specificity

 

       to these various glutamine-containing --

 

                 (Simultaneous discussion.)

 

                 DR. KASARDA:  Not personally, but other

 

       people have.  There are certain sequences that are

 

       susceptible to deamidation and probably

 

       transamidation as well.  These have been described

 

       in some recent publications.  There are many sites

 

       in the gliadins that are susceptible to

 

       transglutaminase.

 

                 DR. CALLERY:  The transglutaminase I

 

       understood was an important feature in binding

 

       these proteins and causing the --

 

                 (Simultaneous discussion.)

 

                 DR. KASARDA:  Well, you know, in the MHC

 

       proteins there is a positive charge in the binding

 

       pocket that binds well to a negatively charged

 

       glutamic acid.  This does enhance the strength of

 

       the binding to the binding site of DQ2/DQ8.

 

                 Now, I didn't get into it, although

 

       possibly someone else will, there seems to be two

                                                                111

 

       legs to the celiac disease situation.  There is the

 

       adaptive immune system, which has been worked on

 

       quite a bit in terms of this presentation of

 

       gliadin peptides to T-cells, to the T-cell

 

       receptor, and stimulation along that leg.

 

                 However, one of the peptides I described

 

       that Mike Marsh had studied, that particular

 

       peptide is not immunoactive.  It does not stimulate

 

       the T-cells, yet when instilled directly into the

 

       small intestine it produced changes that were

 

       characteristic of celiac disease.

 

                 In the last couple of years, there has

 

       been an interest in the role of the innate immune

 

       system in possibly triggering the first leg of

 

       celiac disease, which then progresses on to involve

 

       the adaptive immune system and the CD4 T-cells of

 

       the lamina propria.

 

                 I think that part is becoming pretty well

 

       understood.  Ludvig Sollid and his co-workers,

 

       while he was on sabbatical at Stanford, they

 

       actually crystalized a DQ2 with the gliadin peptide

 

       in the binding site.  They have defined a number of

                                                                112

 

       characteristics of the peptides that are important

 

       for binding.

 

                 However, I think we still don't understand

 

       a good part of what is active or toxic about these

 

       peptides, and it may have to do with this

 

       triggering and innate immune response.  That is

 

       research that is really developing right now.

 

                 CHAIRMAN DURST:  Soheila.

 

                 DR. MALEKI:  Soheila Maleki, USDA.

 

       Essentially, the substrate for the transglutaminase

 

       is the same peptide that is presented by the

 

       antigen-presenting cells?

 

                 DR. KASARDA:  Well, after you deaminate a

 

       particular glutamine, then the binding strate goes

 

       up for the receptor site on the MHC protein.

 

                 DR. MALEKI:  Essentially, it is the same

 

       substrate, just after deamination --

 

                 (Simultaneous discussion.)

 

                 DR. KASARDA:  Well, there is also the

 

       question of, Why do you have antibodies to the

 

       transglutaminase?  This may involve transamination

 

       reactions where you get a binding of gliadin in the

                                                                113

 

       transglutaminase, and then this triggers the

 

       apparent autoimmune antibodies to transglutaminase.

 

                 DR. MALEKI:  I see.  Well, I just find it

 

       amazing that when you show the lineup of the

 

       peptides, the homology, that you had a two amino

 

       acid difference and went from immunoreactive to

 

       non-toxic.  I'm sure by now they probably can

 

       explain that?

 

                 DR. KASARDA:  No, they can't.

 

                 DR. MALEKI:  Well, even in the fitting up

 

       to the transglutaminase or to the processing by

 

       antigen-presenting cells?

 

                 DR. KASARDA:  Well, it is very puzzling,

 

       very interesting.  I really can't answer your

 

       question.

 

                 DR. MALEKI:  Thank you.

 

                 CHAIRMAN DURST:  Any further discussion?

 

                 (No verbal response.)

 

                 CHAIRMAN DURST:  All right.  Thank you,

 

       Dr. Kasarda.

 

                 We are now scheduled for a break.  We are

 

       just about on schedule, so we will take a brief

                                                                114

 

       break and reconvene at 10:45.

 

                 (Thereupon, from 10:25 a.m. to 10:45 a.m.,

 

       there was a pause in the proceedings.)

 

                 CHAIRMAN DURST:  Our first speaker after

 

       the break is Dr. Alessio Fasano, professor of

 

       pediatrics, medicine and physiology and director of

 

       the Mucosal Biology Research Center, Center for

 

       Celiac Research, University of Maryland School of

 

       Medicine.

 

                           PROSPECTIVE STUDIES

 

                 DR. FASANO:  Thanks so much.  I've got to

 

       do this.  I need really to thank the FDA, who has

 

       been so kind to invite me, but also to be so

 

       sensitive to use Italian candies.

 

                 (Laughter.)

 

                 DR. FASANO:  This is very nice of you

 

       guys, and we appreciate that.  I also want to tell

 

       you guys that because of the other speakers, I

 

       decided to reduce a little bit my talk, so a few

 

       slides have been taken out from the handouts to go

 

       straight to the point.

 

                 There has been a general perception that

                                                                115

 

       this is a quite young disease, in other words,

 

       something that we are dealing with kind of

 

       recently. I want to put this in the right

 

       perspective and give you some of the background to

 

       justify this prospective study to decide what is

 

       threshold of tolerable gluten.

 

                 First of all, believe it or not the first

 

       trace of a description of this disease goes back to

 

       the Roman Empire.  This is not something that has

 

       happened in the last few years.

 

                 (Slide.)

 

                 DR. FASANO:  Who really put the disease on

 

       the map is this fellow here.  Samuel Gee, at the

 

       end of the past century, around 1890, gave an

 

       historical lecture to a place where I had the

 

       privilege to study for a little while at Saint

 

       Bart's Hospital in London.

 

                 He really put celiac disease on the

 

       "scientific map."  I took little sentences here and

 

       there from his lectures to give you the sense of

 

       how this guy got the story right more than 120

 

       years ago.

                                                                116

 

                 He described these as a chronic

 

       indigestion that is met in every single age.

 

       Again, our misconception in the past was celiac

 

       disease was confined to a specific age group.  He

 

       knew already that was not the case; it can affect

 

       at any age.

 

                 Of course, it is particularly more

 

       frequent in all kids between one and five years

 

       old, and that was the observation at the time.  He

 

       spent time and effort to clarify the fact that

 

       everybody can be affected.

 

                 Now, symbiotics, hands-on, was the way to

 

       do a disease diagnosis at that time.  We didn't

 

       have a lot of sophisticated tools, so it was really

 

       hands-on.

 

                 For a gastroenterologist, dealing with a

 

       problem like that means describing feces, stools,

 

       and that's what it is.  He introduced with this

 

       description a very important concept about celiac

 

       disease in terms of classical GI presentation,

 

       malabsorption.

 

                 In other words, right before they would

                                                                117

 

       know about the genetics, right before they would

 

       know about the grains, the eyes are telling us that

 

       the feces are loose, malformed, but not watery,

 

       definitely more bulky than the food taken seems to

 

       account for, i.e., malabsorption.

 

                 What is remarkable is this part here.  He

 

       ventured also to understand what was the

 

       pathogenesis of the disease and introduced two

 

       concepts: the genetics and environmental trigger.

 

                 He said kids that suffer from it are not

 

       all weak in constitution, errors in diet.  I want

 

       to clarify that the first time that the link

 

       between celiac disease and grains was made was soon

 

       after World War II.  Until then we had no clue

 

       whatsoever what was the trigger leading to celiac

 

       disease.

 

                 The link was made during World War II

 

       because there was a higher rate of mortality among

 

       kids in Middle Europe that was not explained.

 

       During World War II, grains were not available

 

       anymore.

 

                 They were fed with potato starch, potato

                                                                118

 

       flour, and the mortality dropped dramatically, to

 

       reappear after the end of the war when flour was

 

       again available.  That is when the link was made.

 

                 This guy is already there.  Errors in diet

 

       may be perhaps a cause, but whatever.  Why, out of

 

       a family of kids all brought up in a much similar

 

       way, should only one suffer?

 

                 Again, he is trying to understand what is

 

       the genetic component, what is the environmental

 

       component, why some people have got it and some not

 

       from the same family eating the same stuff.

 

                 Then, he finished up by saying, "Okay, I

 

       think that I have a way to get to the bottom line

 

       in treatment.  The treatment has to be regulating

 

       food in the main part of the treatment.  It is

 

       amazing if you come already with this conclusion.

 

       The allowance of farinaceous food must be small.

 

       Again, I find this remarkable.  Highly starchy

 

       food, rice, sorghum, corn-flour are unfit.

 

                 Now he is losing himself a little bit when

 

       he says malted food is better.   Also, rusks or

 

       bread, provided it is cut thin and well-toasted on

                                                                119

 

       both sides, will be all right.

 

                 Grant him the benefit of that.  I believe

 

       that, again, in 1890 making this kind of statement,

 

       even if he [made] this little boo-boo here, I think

 

       that it is absolutely remarkable.

 

                 (Slide.)

 

                 DR. FASANO:  Now, fast forward that 120

 

       years later, and that is what we understand about

 

       celiac disease.  You heard from Dr. Kasarda and

 

       Dr. Murray already that this is an immune-mediated

 

       reaction.

 

                 It is not an allergic reaction, but rather

 

       right now we really truly believe that this is an

 

       autoimmune condition.  In other words, we are in

 

       the same kind of range as multiple sclerosis, type

 

       1 diabetes, and so on and so forth.

 

                 Therefore, as such there are two key

 

       elements to develop the disease:  You have to be

 

       genetically susceptible.  I'm not going to spend

 

       more time about this DQ2/DQ8, but they are the

 

       docking station, the "eyes," of the autoimmune

 

       system to see the trigger from the environment

                                                                120

 

       coming in.

 

                 It is unique because the only other

 

       autoimmune disease for which we know everything

 

       specifically is the only autoimmune disease for

 

       which we know the trigger, that is, gluten.

 

                 I wish that we had that kind of

 

       information for other autoimmune diseases, for

 

       which we will have a solution.  Theoretically, we

 

       have on hand the possibility of treatment of this

 

       disease.

 

                 However, I will argue that unless we have

 

       a clear rule of engagement, i.e., a food labeling

 

       bill that will really clearly define what is

 

       "gluten-free," this is a theoretical solution but

 

       very difficult to put in practice.

 

                 (Slide.)

 

                 DR. FASANO:  Again, it is pretty obvious

 

       that you have to have these two ingredients, you

 

       have the genes and you have to have the grains.

 

       When they interplay, you may end up developing

 

       celiac disease.

 

                 We heard already that variability in terms

                                                                121

 

       of the timing, how long it is going to take, the

 

       outcome in terms of symptoms, and so on and so

 

       forth, is unbearable.  However, they are all under

 

       the same kind of umbrella of celiac disease.

 

                 What are our treatment options at the

 

       moment?  If these two elements are absolutely

 

       necessary to developing the disease, I believe it

 

       is a no-brainer, it is pretty simple, there are

 

       only two solutions.

 

                 First, we can remove the genes, and I

 

       don't think that we can do that.  We are not quite

 

       there yet anyhow.  As Dr. Murray explained, we know

 

       some of them but we don't know all of them.  Or,

 

 

       secondly, we eliminate the grains.  Those are the

 

       options that we have available.  There is no other

 

       way to turn from this.

 

                 Don Kasarda went extensively into this.  I

 

       didn't know that he was invited, by the way.

 

       However, the bottom line is the only treatment

 

       right now is strict, lifelong -- as you heard, you

 

       don't grow out of this, so you have got to endure

 

       it for the rest of your life -- avoidance of wheat,

                                                                122

 

       rye and barley.  The oats story, again, I am not

 

       going to go back because you heard about that.

 

                 (Slide.)

 

                 DR. FASANO:  It is pretty obvious what are

 

       the major sources of gluten.  This is the easy part

 

       when you have to deal with the patients freshly

 

       diagnosed.  It is easy to say, "You know what?  No

 

       bread, pasta, pizza, beer, cookies, muffins, and so

 

       on and so forth.

 

                 (Slide.)

 

                 DR. FASANO:  This is a little bit more

 

       complicated, and that is where I believe a food

 

       labeling bill will help.  Of course, it is not

 

       necessary to go and say, "You know what?  This

 

       muffin that you buy at the bakery needs a label."

 

       We know that already whether it is gluten-free.

 

                 However, this stuff here (showing "Sources

 

       of Gluten" slide) definitely needs a label, some of

 

       them, because it is not clear if they have gluten

 

       or not because they can be processed with or

 

       without gluten.

 

                 Gluten is a formidable, extremely cheap

                                                                123

 

       biological glue.  Don told you the physical,

 

       chemical characteristics of the molecule.  The

 

       reason why manufacturers use that is because when

 

       you have two elements of a processed food that does

 

       not stick together, the cheapest way to keep them

 

       together over time is to use gluten.  Right now,

 

       the label can see just the nature of flavor but not

 

       gluten, not necessarily so.

 

                 Then, there are really the tough ones in

 

       which, this is not even food really, a source of

 

       gluten needs to be considered.  I can't

 

       conceptualize enough how many times we've gotten

 

       E-mails of people asking, "Is my husband, who has

 

       celiac disease, going to be sick or whatever," or

 

       the Playdough for the kids in kindergarten, and so

 

       on and so forth.  These are elements to keep in

 

       mind that we deal with all the time.

 

                 Of course, the big deal is right here --

 

       medications, prescriptions.  As for foods,

 

       processed foods, also medication they enjoy gluten

 

       as an additive to keep elements together.

 

                 Now, while I was saying adhere to a diet

                                                                124

 

       is a pure theoretical no-brainer, but in a

 

       practical sense it is extremely complicated.  It is

 

       a chronic intervention that you have to do, and you

 

       have to stick with it with full commitment for the

 

       rest of your life.

 

                 Every single individual in this room I am

 

       pretty sure that you have made some commitments

 

       here and there to go on a certain diet or to

 

       exercise or to decide to change your lifestyle.  To

 

       keep that constantly for the rest of your life, it

 

       takes a lot of stamina.  That is the reality of the

 

       story.

 

                 That is true particularly in the American

 

       society in which any chronic illness will require

 

       chronic treatment, whether it be diet or exercise

 

       or medication or whatever, will pose a problem of

 

       compliance.  Definitely among different

 

       interventions, a diet compliance can be really a

 

       difficult aspect of treatment.

 

                 In my book, food is one of the few joys in

 

       life.  How many times do we leave home and go to

 

       work, we drive, we don't think about it, and we

                                                                125

 

       find ourselves at work without having to pay

 

       attention to directions, streets, and so on and so

 

       forth?  We are used to it.

 

                 That is the same with food, we are used to

 

       it.  However, that is not the case for celiacs

 

       because they have to think about this over and over

 

       and over again.  It will become not a natural,

 

       spontaneous activity in life, but it will become a

 

       very, very demanding operation.

 

                 (Slide.)

 

                 DR. FASANO:  Why don't people stick with

 

       diets?  This is a survey that was done in

 

       Upstate New York.  This statement, and this is just

 

       to paraphrase something that Cynthia was telling

 

       us:

 

                 "If I eat less gluten, I will have less

 

       intestinal damage."

 

                 Half of the people say, "You know what?  I

 

       really don't have to stay a hundred percent gluten

 

       free.  As far as I decrease this, I will have less

 

       problems.  I will be all right."

 

                 "I've lived this long eating gluten, how

                                                                126

 

       much will a gluten-free diet really help me now?  I

 

       mean, you know, if it's not been a big deal so far,

 

       why should I just dramatically change my lifestyle?

 

       I've survived so far, I'm not going to die from

 

       it."

 

                 "It's not me, that I have to do this.

 

       It's my doctor who should tell me when I need

 

       follow-up testing or whether I need to stick with a

 

       diet, and so on and so forth."  One-fourth of the

 

       people say that.

 

                 Again, you heard Dr. Murray, that

 

       unfortunately some of the confusion is generated by

 

       the professionals, the healthcare professionals.

 

       They don't know the rule of the game, and,

 

       therefore, they cannot transmit how to play the

 

       game.

 

                 It is pretty much the sense that you go to

 

       the doctor as an individual that has to teach you

 

       how to play chess, and this fellow has no clue

 

       whatsoever how to move the pieces.  Patients have

 

       to learn how to play chess while playing against a

 

       professional player.  How fair is that?  It is an

                                                                127

 

       ongoing process.

 

                 This is the one that disturbed me the

 

       most:  "Scientists and doctors still haven't proven

 

       that gluten really hurts them."  You know, there is

 

       no clear information that gluten is dangerous to

 

       celiacs, and that is quite disturbing.

 

                 (Slide.)

 

                 DR. FASANO:  What are the current barriers

 

       in compliance?  Again, you heard about the emotion

 

       of the person, anxiety.  There is a tremendous

 

       reaction when you are diagnosed with a chronic

 

       illness, no matter how you want to put it.  Now,

 

       grief and fear and denial are part of the story.

 

                 The ability to resist temptation and to be

 

       disciplined on a gluten-free diet is tough.  There

 

       are feelings of deprivation.  A few years ago I was

 

       with one of the patients, and he got the chance to

 

       drink a gluten-free beer.  Soon after he started to

 

       drink the beer, I saw tears coming down his cheeks.

 

       His simple statement was, "I've waited 25 years for

 

       this."  Imagine, 25 years to drink again beer.

 

                 He was disciplined, and he didn't touch

                                                                128

 

       it.  However, there are many others, particularly

 

       adolescents, in which that kind of discipline is

 

       really hard to obtain.

 

                 This is very much the heart of the

 

       problem, fear generated by inaccurate information.

 

       If we do not have clear ideas, we, as

 

       professionals, and one says black and the other one

 

       says white, and the other one says up and the other

 

       one says down, that creates a lot of confusion and

 

       a lack of trust.

 

                 (Slide.)

 

                 DR. FASANO:  Other barriers to compliance

 

       are of course we live in a society that drives 150

 

       miles an hour, and we don't have the time to seek

 

       to prepare our food to enjoy.  My kids consider

 

       that the stove is the microwave.  The stove does

 

       not exist.

 

                 Cynthia teaches us the fact that the new

 

       generation believes that cooking is just powder

 

       mixed with water, stick it in the microwave, and

 

       the only thing that you've got to do is read how

 

       long should that go on and that's it.  What

                                                                129

 

       sophistication.

 

                 Here, assessing gluten content in food and

 

       label reading is the most compelling change in

 

       lifestyle that these people go through.  Right now,

 

       I don't know about you guys, but I don't enjoy food

 

       shopping.  I really do not.  I tend to go at

 

       midnight when nobody is there, because I want in

 

       and I want out.

 

                 That is not an option for celiacs.  One

 

       thing that will take you, I don't know, half an

 

       hour will take four or five hours for celiacs

 

       because you've got to read every single label to

 

       the nitty-gritty and make decisions.

 

                 Many times now I see people with cell

 

       phones calling an 800-number right there on the

 

       spot saying, "I have your Box XYZ, is this

 

       gluten-free or not?"  It is cumbersome.

 

                 (Slide.)

 

                 DR. FASANO:  All of this to come to the

 

       heart of what I'm going to share with you guys.

 

       How much is too much?  Unfortunately, I can't

 

       conceptualize and stress enough what Cynthia

                                                                130

 

       already said.  In biology, the absolute zero does

 

       not exist.  If you really do believe that we can

 

       achieve zero as gluten-free, this is a pure

 

       theoretical concept that nobody will ever be able

 

       to achieve.

 

                 Assume, just for a moment, that we will

 

       have a sophisticated,  super-duper sophisticated,

 

       monoclonal ELISA to really go down to zero.  To

 

       manufacture food in that way, people in that

 

       particular factory should be dressed with spray

 

       suits, all antiseptic.  A piece of bread will cost

 

       $250, because that is what that level of

 

       sophistication and controlled environments will

 

       take.  Consequently, it is impossible.

 

                 At the same time we need to give industry,

 

       manufacturers, a parameter of what is tolerable and

 

       what is not.  There have been many retrospective

 

       studies that Dr. Collin is going to tell us about,

 

       very few prospective studies because they are

 

       extremely challenging to do right.

 

                 This study that I am going to show you the

 

       data of has really been coordinated by

                                                                131

 

       Dr. Carlo Catassi, who has been involved in this

 

       kind of topic for the past 15 years.  He is a

 

       member of our center, and we have been doing this

 

       in coordination for the past four years.

 

                 Why do we need to do this?  Because again

 

       this is a long-term, strict gluten-free diet.  If

 

       we do a prospective study design, we can answer

 

       questions that a retrospective study was not able

 

       to answer.

 

                 How we did this?  We did it in a way that

 

       the gluten-free diet, people that come in are

 

       already diagnosed on a gluten-free diet.  We are

 

       monitoring this gluten-free diet in a blind fashion

 

       where a given amount of gluten is added to the

 

       diet, then, the clinical, serological and biopsy

 

       evaluation before and after the microchallenge.

 

                 The background noise, this is very

 

       important, is caused by possible contamination of

 

       the food was minimized by using a control group, in

 

       other words, to really do this by the book.

 

                 (Slide.)

 

                 DR. FASANO:  Studies done in the past, for

                                                                132

 

       example, from Dr. Catassi almost a decade ago,

 

       showed a linear relationship between the amount of

 

       gliadin -- that is the toxic part of the story here

 

       -- a daily dose, and it causes damage between 100

 

       and 1,000 milligrams a day.

 

                 The intraepithelial lymphocytes -- and we

 

       are going to go back to what these intraepithelial

 

       lymphocytes are all about, the meaning -- was the

 

       most sensitive index, not the serology and not the

 

       symptoms.

 

                 What you heard already from Dr. Murray is

 

       that after all these red flags the antibodies may

 

       not be sensitive enough to uncover exposure to

 

       gluten.  Indeed, even 10 years ago this was very

 

       clear.

 

                 (Slide.)

 

                 DR. FASANO:  Why do this again?  If it was

 

       done 10 years ago, why revisit this if we have

 

       already the information?  Several reasons.  The

 

       need, first of all, to investigate the effects of

 

       lower gluten doses.  Because at that time they were

 

       using large doses, because that was the level of

                                                                133

 

       sensitivity of the tests for the foodstuff.

 

                 There is a need for prolonging the

 

       duration of the microchallenge.  In the past, the

 

       longest that we went was a month, and people would

 

       ask, "How about two months or three months?"

 

                 How about if the period, the lag period,

 

       between the exposure to gluten and when you react

 

       is longer?  You believe it to be safe for one

 

       month, but you keep going, and eventually you

 

       react.

 

                 There is a need of a control group that

 

       was never used before, and, most importantly, you

 

       heard that gliadin is part of the story.  They are

 

       the glutamines.

 

                 If you do the study just as done in the

 

       past, you may really not uncover what is really the

 

       story; in other words, what you leave out there is

 

       not pure gliadin but rather this mixture of

 

       proteins that Don Kasarda was telling us about.

 

                 (Slide.)

 

                 DR. FASANO:  I don't want to spend too

 

       much time on this, but for a matter of

                                                                134

 

       quantification, to give a sense of what we are

 

       talking about.  In 200 grams of wheat-based

 

       products -- bread, pasta, so on and so forth -- you

 

       heard that the main proteic fraction in wheat is

 

       gluten.  For 8 to 14 percent of the overall amount

 

       is wheat.  Gluten is 75 percent of all the protein.

 

       Between gluten and glutamine, we can say that all

 

       of this 8 to 14 percent are these toxic proteins

 

       for celiacs.  This 8 to 14 percent translates into

 

       15 grams.

 

                 The real toxicity, the main toxic, is due

 

       to the gliadins.  Again, glutamines contributed to

 

       toxicity.  Of the 200 grams, 8 to 14 percent is

 

       equal to 15 grams.  Half of it is gliadin.  Gliadin

 

       has more than 50 toxic fragments, and so on and so

 

       forth.

 

                 If you go on a gluten-free diet, an adult

 

       that is on a gluten-free diet, roughly, consumes --

 

       I mean, in a normal diet, roughly, the amount that

 

       you consume is this, 15 grams.  Roughly, you

 

       consume 200 grams of wheat-based products.

 

                 If you are on a gluten-free diet, a

                                                                135

 

       typical gluten-free diet, the subject consumes

 

       gluten-free flour-based, that is roughly 80 grams.

 

       The key element is how much of this 80 grams of

 

       gluten-free products can be contaminated with the

 

       toxic element, gluten?  How much is the amount that

 

       you can tolerate?  That is the heart of the problem

 

       here.

 

                 (Slide.)

 

                 DR. FASANO:  That prompted the design of

 

       the study.  It is a quite complicated study.  The

 

       aim was to evaluate the consequences of the

 

       protracting just minimal intake, either 10 of 50

 

       milligrams, a very small intake.

 

                 In a group of adult celiacs on long-term

 

       treatment with the gluten-free diet, why this

 

       amount?  Because, again, 100 milligrams was already

 

       tested and proved to be dangerous 10 years ago.

 

                 How the study was designed was as a

 

       multicenter, prospective randomized,

 

       placebo-controlled, double-blind and was a

 

       three-year study.  It was entirely sponsored by the

 

       Italian Celiac Society.

                                                                136

 

                 The reason why we did it in Italy, as I

 

       was mentioning before, is mainly because economical

 

       support of such a complicated and expensive study

 

       could be executed at this time only in a place

 

       other than the United States where we don't have

 

       that kind of resources.

 

 

                 (Slide.)

 

                 DR. FASANO:  Who was eligible?  Patients

 

       with biopsy-proven celiac disease had to be on a

 

       gluten-free diet for at least two years.  These

 

       people that had been diagnosed with all of the

 

       criteria are accepted and have to be complying with

 

       the diet for at least two years.

 

                 If you are younger than 18 years old, poor

 

       compliance, abnormal results at the baseline

 

       evaluation or you have IgE deficiency, that will be

 

       an exclusion criteria.

 

                 (Slide.)

 

                 DR. FASANO:  Now, how we did this?  Well,

 

       again, these people were heroes to accept such a

 

       study, but this was the only way to do it.  These

 

       people would come in to be scrutinized to see if

                                                                137

 

       they were eligible.

 

                 If they were eligible, a consent form was

 

       obtained and there was an intense, strict

 

       monitoring of their gluten-free diets for a month

 

       before the beginning of the study was obtained.

 

       Baseline clinical serological and a biopsy was

 

       obtained.  In other words, they underwent a

 

       endoscopy with a biopsy to show that they were

 

       fine.

 

                 They were blindly randomized in three

 

       groups, either no gluten, 10 milligrams of gluten

 

       or 50 milligrams of gluten.  They were followed for

 

       three months.  At a monthly interval there was a

 

       check with the serologist for symptoms.

 

                 At the end of the study, at the end of the

 

       three months, once again there was a clinical

 

       evaluation and a serological evaluation and a

 

       second intestinal biopsy under endoscopy.

 

                 This was the kind of study that this was

 

       the only way, given the fact that the we know

 

       symptoms and serology tests cannot be sensitive

 

       enough to do this right.

                                                                138

 

                 (Slide.)

 

                 DR. FASANO:  The purified gluten was used

 

       for the challenge.  Gluten -- or lactose-containing

 

       placebo -- capsules were randomly prepared.  The

 

       lab tests were centralized.  There was monthly

 

       monitoring of adherence to the protocol; it was

 

       checked by a nutritionist.

 

                 Measurement of gluten contamination in

 

       commercially available gluten-free food that they

 

       had during the challenge was checked by ELISA.  The

 

       serum AGA and anti-tTG antibodies were checked; a

 

       biopsy was performed with morphometry; there was an

 

       intraepithelial lymphocytes count; and control

 

       biopsies from non-celiac patients were used.

 

                 (Slide.)

 

                 DR. FASANO:  These are the foods that they

 

       had a gluten-free foods.  You keep in mind that in

 

       Italy right now the food labeling policy is to be

 

       labeled as gluten-free you have to have 20 parts

 

       per million or less.

 

                 Indeed, with this simple exception, the

 

       vast majority of the foods that these people there

                                                                139

 

       are eating was gluten-free, by definition of the 20

 

       parts per million.

 

                 Consequently, the only gluten that these

 

       people were seeing was actually the ones that were

 

       dealing with the challenge, if they were in the

 

       group of gluten exposure.

 

                 (Slide.)

 

                 DR. FASANO:  We were able to recruit 39

 

       people, who were divided equally into three groups.

 

       There were a couple of things that were interesting

 

       to us.

 

                 Of all the parameters that we measure, two

 

       are extremely important to establish the health of

 

       the intestine and the exposure to gluten damage,

 

       one was the villous height/crypt depth ratio.  It

 

       is very typical use of morphometric analysis that

 

       we do in clinical practice.

 

                 Typically, we want to see this: roughly, a

 

       ratio of 3:1.  In other words, the height of the

 

       line has to be 3 times the depth of the crypt.

 

       That is what typically we consider to be normal.

 

                 Despite the fact that they were on a

                                                                140

 

       gluten-free diet, despite that, they fulfilled the

 

       criteria.  They were gluten-free, symptom-free,

 

       immunologically negative, and all the 9 yards.

 

       They went on a one-month controlled diet.

 

                 When we did the starting biopsy, there was

 

       a slight decrease of the villus-crypt ratio,

 

       meaning, the villi were a little bit shorter.  That

 

       is what happens when you have an insult, the villi

 

       become short and the crypts go deeper.

 

                 The other parameter is the number of

 

       CD3-positive cells, the intraepithelial lymphocytes

 

       if you wish, was again 20 per hundred entrocytes

 

       and controls and 30 in the celiacs on a gluten-free

 

       diet.

 

                 Therefore, at baseline already something

 

       was going on.  It is like there is a status of

 

       inflammation in which this is like a very

 

       well-trained athlete, ready to react to anything if

 

       it smells gluten coming through.  It is really at

 

       the edge, ready to jump.

 

                 There was a strong correlation between the

 

       number of intraepithelial lymphocytes and the

                                                                141

 

       villus/crypt ratio, meaning, that the more healthy

 

       is tissue, the less intraepithelial lymphocytes.

 

       The healthier the tissue -- when the crypts are

 

       elongated and the villa get short, the more

 

       intraepithelial lymphocytes are there.  The

 

       intraepithelial lymphocytes are really soldiers

 

       that the immune system sensed at the forefront and

 

       ready to fight the battle.  That is what it is.

 

                 (Slide.)

 

                 DR. FASANO:  Now, what kind of symptoms

 

       after the three months these people experienced in

 

       the three groups?  There were not really

 

       significant differences: abdominal distention,

 

       anemia, iron deficiency, loss of appetite,

 

       bloating, and so on and so forth.

 

                 There were equally distributed in all

 

       groups including the placebo, but two really stand

 

       out -- all in the 50 milligrams.  This stomatitis

 

       and the mouth, there are the typical signs of

 

       mucosal involvement of the oral cavity in celiacs,

 

       well-described, it was present only in the

 

       50 milligrams.  Weight loss was experienced only in

                                                                142

 

       the 50 milligrams.  For the rest, we didn't see any

 

       major differences.

 

                 To revisit the concept that the antibodies

 

       were useless -- these are the antibodies, IgA and

 

       anti-tTG and IgG anti-gliadin antibodies -- before

 

       and after the challenge in placebo 10 and 50

 

       milligrams, there was no difference.  Pretty much

 

       there was no difference among the groups.

 

                 What we saw as the difference was the

 

       villus/crypt ratio, that all in the 50 milligrams

 

       started to decrease to a level of significance.

 

       After three months, we saw the crypts become a

 

       little bit deeper and the villi to become a little

 

       bit shorter.  This translates in the fact that

 

       there was damage that started to occur, or possibly

 

       damage that started to occur.

 

                 The intraepithelial lymphocytes, there are

 

       these spots here (indicating).  Again, these are

 

       lymphocytes under normal circumstances you see in a

 

       smaller quantity in between epithelial cells.

 

                 It came to be of a very increased number

 

       in people with 50 but not in 10, not reaching

                                                                143

 

       statistical significance, but these are trends that

 

       I have the obligation to report.  It is not

 

       significant that there are more of these cells in

 

       the 50 milligrams compared to the starting point,

 

       but it is a trend there.

 

                 (Slide.)

 

                 DR. FASANO:  I believe the heart of all of

 

 

       this is this table.  I believe this really cuts to

 

       the chase.  It is extremely confusing, particularly

 

       to patients, when you talk about milligrams and

 

       parts per million.  What the heck are you talking

 

       about?  Why do we use this parameter of parts per

 

       million and not just straight milligrams?

 

                 Because, by the way, say, you do the study

 

       and you show that 50 milligrams could be dangerous,

 

       so how can it be 10 milligrams?  How much is 10

 

       milligrams?  How much of a pizza is 10 milligrams?

 

       You say, "Well, let me give you the bad news.  It's

 

       less than a fraction of a crumb of a piece of

 

       bread.  That is what we're talking about.

 

                 Still, it doesn't give you clearly what is

 

       the magnitude of the stuff that we are talking

                                                                144

 

       about.  The reason why we prefer to express in part

 

       per million rather than in milligrams is because

 

       the amount that is tolerable really depends on how

 

       much you eat.

 

                 (Slide.)

 

                 DR. FASANO:  As you see here, this is the

 

       daily intake of gluten-free flour or whatever

 

       products are based on gluten-free.  If you eat

 

       50 milligrams, of course you end up to ingest much

 

       less than 300 milligrams of the substance that you

 

       are eating.

 

                 Let's say that, for example, we set the

 

       parameter at 200 parts per million.  If we want to

 

       accept the outcome of this study as something to

 

       keep in mind, 10 milligrams is safe for everybody,

 

       50 milligrams start to be questionable.

 

                 If you set the threshold at 200 parts per

 

       million, if you eat a relatively small amount of

 

       the stuff a day, you are okay.  If you eat a little

 

       bit more, you are in an area that we don't quite

 

       know, because again it is between 10 to 50

 

       milligrams.  You can argue, "Is 40 okay?  Is 30

                                                                145

 

       okay?"  We don't know.

 

                 Definitely, if you eat 300 grams a day --

 

       in other words, you eat large amounts of

 

       gluten-free products that is contaminated to the

 

       level of 200 parts per million -- you start to go

 

       into the red zone.  That is dangerous.

 

                 If you go down this table, you see that if

 

       you set 20 parts per million, no matter how much

 

       your Italian lifestyle of eating like crazy food

 

       that is gluten-free based, no matter how far you

 

       go, you still are well below the threshold.

 

                 Therefore, at least based on this study,

 

       that I believe has been done really the way that it

 

       is supposed to be done, long enough, because three

 

       months is definitely a long period, a threshold of

 

       20 parts per million should be safe for the vast

 

       majority of the people because it will keep you way

 

       below the cutoff that seems to be dangerous, i.e.,

 

       the 10 milligrams.

 

                 (Slide.)

 

                 DR. FASANO:  Now, this litany of names is

 

       just to explain that this was not a trivial study. 

                                                                146

 

       It was a multicenter study that involved a

 

       tremendous amount of work and a tremendous amount

 

       of dedication of people that have no business to

 

       undergo this, particularly two endoscopies with two

 

       biopsies.  However, it is only because of the

 

       dedication and the commitment of these people that

 

       we have an answer and we have a chance to come to

 

       you today with something that is a little bit less

 

       foggy than so far we have had in terms of

 

       prospective studies.

 

                 I will stop there, and I will take any

 

       questions that you have.

 

                 CHAIRMAN DURST:  Thank you very much.

 

                       QUESTION AND ANSWER SESSION

 

                 CHAIRMAN DURST:  Questions?

 

                 Margaret.

 

                 DR. BRILEY:  Margaret Briley.  Can you

 

       tell me, I didn't understand, how often did they do

 

       the biopsies?  Every month?  Every three months?

 

                 DR. FASANO:  No.  No, no, no, that would

 

       kill us if we do it every month.  No, the biopsy

 

       was done at the beginning of the study, at the

                                                                147

 

       entrance, and at the end of the study, three months

 

       after, the idea being how much insult did you get

 

       in two months.

 

                 What was done at intermediate intervals

 

       was a survey of the diet, to make sure that they

 

       were complying with a gluten-free diet, survey

 

       compliance of taking the pill, and the serological

 

       tests for the antibodies.  Those were done on a

 

       monthly basis.

 

                 DR. BRILEY:  On a monthly basis?

 

                 DR. FASANO:  That's right.

 

                 DR. BRILEY:  Thank you.  That was good.

 

                 CHAIRMAN DURST:  Erica.

 

                 DR. BRITTAIN:  Erica Brittain.  If I'm

 

       understanding correctly, the conclusion of the

 

       study is that 10 milligrams daily would be safe,

 

       was shown at least to be fairly similar to your

 

       placebo group in this four-month exposure.  How

 

       would you know how that would translate to four

 

       decades of exposure?

 

                 DR. FASANO:  Only with decades of

 

       prospective study.  You are a statistician, and you

                                                                148

 

       know better than I do that you've got to start

 

       somewhere.

 

                 There is no question in my mind that the

 

       only way to do that is like when you put a new drug

 

       on the market, and you go to Phase I and you do 10

 

       people.  When you do Phase II, you do 100 people.

 

       You do Phase III, and 10,000 people.  Everything is

 

       fine.  Ten years later, because millions of people

 

       took it, it may be that something wrong will come

 

       up, a classical example.

 

                 I don't have an answer for you.  How do I

 

       know in 10 years what's going to happen?  But, you

 

       know, we have to have some way to start.  I believe

 

       that this study is giving us a parameter, a

 

       justification, a scientific rationale to say,

 

       "Let's start here."

 

                 CHAIRMAN DURST:  Okay.  Soheila.

 

                 DR. MALEKI:  Soheila Maleki.  I was just

 

       wondering, this is probably not directly related to

 

       your topic, I heard earlier mention of wheat flour

 

       and exposure.  How much is inhaled exposure

 

       involved in some of these reactions?

                                                                149

 

                 DR. FASANO:  I don't think that anybody

 

       can answer with scientific confidence that inhaling

 

       is or is not a possible port of entry of gluten for

 

       people with celiac disease to react to.

 

                 What we know as a fact, an undisputable

 

       fact, is that the intestine is the port of entry,

 

       the key port of entry.  I can tell you anecdotally

 

       that we have patients that react to inhalation of

 

       gluten leading to asthma as an allergic reaction to

 

       gluten rather than to celiac disease.

 

                 How confident am I that this could be an

 

       alternative to the other route?  I'm not really

 

       confident, because I don't think that we have the

 

       scientific proof beyond any reasonable doubt, as we

 

       do with the other route, that it could be a

 

       possibility.

 

                 DR. MALEKI:  Thank you.

 

                 CHAIRMAN DURST:  Ciaran.

 

                 DR. KELLY:  Yes.

 

                 Thank you, Alessio, I agree.  Thank you

 

       for sharing the data with us, and I agree that at

 

       least it is a basis that we can begin to work from

                                                                150

 

       and make some rational approaches to what is best

 

       for our patients with celiac disease.

 

                 A couple of questions:  The first relates

 

       to the earlier question about the 40-year

 

       experiment.  There is one that there is a

 

       20 part-per-million threshold set already in Italy.

 

       Could you comment on how well that is tolerated by

 

       every or the vast majority of celiac patients in

 

       Italy?

 

                 DR. FASANO:  Actually, it is much more

 

       than that.  There are interesting natural

 

       experiments being done.  Italy for many years now

 

       reinforced the 20 parts per million.  England has

 

       this 20 to a hundred, and so on and so forth.

 

                 As far as I can tell you, this is

 

       something that in Italy the food labeling

 

       legislation setting it at 20 parts per million has

 

       been there for 7 years.  It has been considered to

 

       be absolutely safe with very sporadical reports of

 

       reactions.

 

                 Now, I think it was telling you when you

 

       have a stomachache and you are a celiac, you tend

                                                                151

 

       to go that way to the extreme that some people say,

 

       "Today's ache is because I had gluten."

 

                 I mean, this is the reality of the story.

 

       But if you want to, statistically speaking, work on

 

       the large numbers, I would say that 20 parts per

 

       million has been proved to be safe.

 

                 DR. KELLY:  In your study, then, and this

 

 

       is something that we discussed a lot yesterday in

 

       the context of food allergy and challenge studies,

 

       is there the potential for bias in selection; in

 

       other words, individuals who are highly sensitive,

 

       in terms of symptomatically highly sensitive, to

 

       low levels of gluten would either be afraid or not

 

       choose to enter the study?

 

                 DR. FASANO:  Absolutely.  Absolutely, no

 

       question about it.  The reality of the story is

 

       that if you are extremely sensitive to gluten, you

 

       would be less willing to expose yourself to

 

       something that you know is going to harm you.

 

                 The point is, What percentage of the

 

       population does that represent?  Is it 10 percent,

 

       20 percent, 50 percent, or a fraction of 1 percent

                                                                152

 

       of the celiac population?

 

                 You know, I'm pretty sure everybody that

 

       is involved in the clinical care of people with

 

       celiac disease has run into people who are

 

       extremely, extremely sensitive to gluten out there.

 

       The exception are people where actually the problem

 

       is the opposite; these are people who can eat

 

       dangerous amounts of gluten and they do not react.

 

       That is a problem.

 

                 CHAIRMAN DURST:  Dick Durst.  Just to

 

       follow up on that, How did you recruit the people

 

       for these studies?

 

                 DR. FASANO:  The method of recruitment is

 

       a major advantage of the Italian setting is that

 

       there is a single Celiac Society, and they are

 

       extremely committed.  What we did was very simple.

 

       They have a national bulletin, both electronically

 

       and on paper, that is read pretty much by the vast

 

       majority of the members of the celiac community.

 

                 I believe that we originally asked for 45

 

       volunteers.  That is the number that the

 

       biostatistician told us to go for to have a

                                                                153

 

       meaningful outcome.  We got 470 volunteers, so we

 

       had to turn people down.

 

                 CHAIRMAN DURST:  Did you at that point

 

       know which ones were the hypersensitive or the more

 

       sensitive versus other and select on that basis at

 

       all?

 

                 DR. FASANO:  No.  The way that these

 

       people were selected was completely random.  In

 

       other words, the least that we had every "X," three

 

       or four up -- I don't know, to make the number --

 

       were called to make that unbiased.  We really

 

       wanted a representative portion of the population.

 

       This was done by also sex and age.

 

                 Yes?

 

                 DR. KELLY:  Ciaran Kelly again.  I do have

 

       one other question, and it has to do with the

 

       interpretation of the data on villus/crypt ratio

 

       and IEL counts in the controls versus the

 

       well-controlled celiacs.

 

                 You showed that there was a small

 

       difference at baseline, even though those

 

       individuals were doing well on a gluten-free diet. 

                                                                154

 

       Your interpretation is that there is an underlying

 

       immune activation.  My question is, Is it possible

 

       or likely or relevant that the 20 parts per million

 

       that they are taking is perpetuating that?

 

                 DR. FASANO:  What I am trying to convey is

 

       the difference is that the recovery -- even if you

 

       are completely, religiously gluten-free -- is not

 

       100 percent.  That is what I meant.

 

                 I don't know if this is due to an ongoing

 

       immune response.  I believe that to not probably be

 

       the case.  Because after all, after all with all of

 

       the machinery in the community, these people have

 

       been proved not to go back to normal.  Whereas,

 

       again, the fact is that no matter how you push it,

 

       you can't really go back to normal.

 

                 I think that the fact that for three

 

       months, even if you were really "touched," so to

 

       speak, you did not react to 10 milligrams.  For me

 

       it was a great level of confidence that this is the

 

       way to go -- together again with data with a

 

       retrospective study, that we are going to hear

 

       about in a moment, and on-the-field exercise in

                                                                155

 

       Italy.

 

                 CHAIRMAN DURST:  Jean?

 

                 MS. HALLORAN:   Another question about the

 

       sample group.  When you did the baseline study, how

 

       much variability did you find in the members of

 

       that group?

 

                 DR. FASANO:  Let me see if I can go back

 

       on this.

 

                 MS. HALLORAN:   You had two factors that

 

       you looked at, the villus height --

 

                 DR. FASANO:  Can you put on the slide show

 

       for a second?

 

                 (Ms. Sylvia Smith complies.)

 

                 DR. FASANO:  You will see that there was

 

       --

 

                 MS. HALLORAN:   Slide 32.

 

                 DR. FASANO:  Can you bring me over there,

 

       please?

 

                 (Slide.)

 

                 DR. FASANO:  There is a fair amount of

 

       variability.  You see that, and there is some

 

       overlapping at baseline.

                                                                156

 

                 If you go down -- keep going -- now, if

 

       you can go up to 28, please?

 

                 (Slide.)

 

                 MS. HALLORAN:  It is 32, I think.

 

                 DR. FASANO:  You want 32?  I thought that

 

       you were talking about the variability of the

 

       villus/crypt ratio.  Is that what you are talking

 

       about?

 

                 CHAIRMAN DURST:  Yes.

 

                 MS. HALLORAN:  Yes.

 

                 DR. FASANO:  It is a little bit higher

 

       than that.

 

                 Can you go higher?

 

                 MS. HALLORAN:  Ah.

 

                 DR. FASANO:  Stop here.  I need 26.

 

                 (Slide.)

 

                 DR. FASANO:  All right.  You see here,

 

       this is the variability.  You see here that this is

 

       the variability.  These are the single points.  If

 

       there was somebody that was high right here

 

       (indicating), and someone like here, these are the

 

       celiacs.  There was a continuum, so it is not that

                                                                157

 

       there are people here, people there; it is a

 

       continuum.

 

                 This is the standard deviation, and this

 

       is the mean.  Again, there is some variability but

 

       not huge.  There is much more variability in the

 

       intraepithelial lymphocytes -- you can see this

 

       scatter -- that are being monitored.

 

                 CHAIRMAN DURST:  Suzanne.

 

                 DR. TEUBER:  Suzanne Teuber.  I would

 

       assume, and this may be a completely incorrect

 

       assumption, that in the population that is

 

       following a gluten-free diet strictly, as those you

 

       indicated you recruited, would actually be a subset

 

       of patients who perceive themselves to be very

 

       sensitive, and thus would have a higher motivation

 

       to follow such a diet.

 

                 This would bring up in Italy what percent

 

       of patients do comply with the gluten-free diet?

 

       We heard about the extreme difficulties here and

 

       the poor compliance rate.  Is it better in Italy?

 

       Would this mean that, perhaps, this population that

 

       you recruited from really might be a good sensitive

                                                                158

 

       population?

 

                 DR. FASANO:  I think, and I'm paraphrasing

 

       Joe Murray on this, that the compliance with the

 

       diet is the results of many factors, some of them

 

       diet there.  Education I believe is at the top of

 

       all.

 

                 It is not that you feel it to be more

 

       sensitive or less sensitive.  If you understand the

 

       facts, if you understand the rules of the game, no

 

       matter how you are perceived as being sensitive or

 

       not sensitive, you know that you can't cheat.  You

 

       know that you need to start with that.

 

                 If you go to 10 doctors and they say all

 

       the same things, "I'm sorry, you don't have an

 

       alternative," then the level of confidence

 

       increases.  We don't have that here.  We don't have

 

       it, honestly.

 

                 Let's be honest.  We have people, doctors,

 

       that will tell you, "You know, you need to go on a

 

       gluten-free diet."  These are the teaching sheets

 

       that were printed 20 years ago.  "After three

 

       months, go back on a regular diet.  You're going to

                                                                159

 

       grow out of it."  What level of confidence do you

 

       have?

 

                 Definitely, a study like here, like this

 

       done here, will have a tremendous amount of bias.

 

       Because who is going to do that?  It will be only

 

       the ones that are extremely compliant.  The

 

       population in Italy that is compliant -- in Italy?

 

                 I should not say in Italy, in Europe --

 

       because they are like 10 or 15 years ahead of us in

 

       this, because the level of awareness has been there

 

       for quite a long time -- is pretty high.

 

                 They understand exactly what is at risk.

 

       That is the reality of the story.  It is more than

 

       to be the people with high cholesterol, high blood

 

       pressure and to be on medication because there is

 

       much more flexibility there.

 

                 These people they understand that if they

 

       don't comply the pay a price, and they do.  The

 

       level of frustration, particularly here, is that

 

       they want to do that, the ones that understand the

 

       game, but they can't because there is no way in

 

       their current situation they can comply.

                                                                160

 

                 CHAIRMAN DURST:  Doug.

 

                 DR. HEIMBURGER:  Doug Heimburger.  Would

 

       you go to the next slide, please, after this one?

 

                 DR. FASANO:  Sure.

 

                 (Slide.)

 

                 DR. HEIMBURGER:  Does this graph include

 

       the controls or only celiac patients?

 

                 DR. FASANO:  These are only the celiacs.

 

                 DR. HEIMBURGER:  Just out of interest, did

 

       you test for this correlation in the controls?

 

                 DR. FASANO:  Yes, it is the same.  We put

 

       it all together, yes.  There is a strong

 

       correlation.  Again, if you conceptualize this

 

       intraepithelial lymphocytes as, again, the first

 

       folks to go there -- just two weeks ago, for

 

       example, there was a paper in science in which they

 

       claimed that the lymphocytes, they are called

 

       gamma/delta, they are able to present antigens.

 

                 They can see gluten and they can start the

 

       entire reaction, at least to the adaptive immunity

 

       Th2 response to interferon-gamma, that will

 

       translate in damage, i.e., to make the villi short

                                                                161

 

       and the crypt deeper.  That makes a lot of sense.

 

       The more you have, the more cytokines you can use,

 

       the more damage you have.

 

                 CHAIRMAN DURST:  Dr. Fasano, will you be

 

       around for the discussion this afternoon?

 

                 DR. FASANO:  Yes.  Yes, I will.

 

                 CHAIRMAN DURST:  Because I think maybe we

 

       will stop the questions.

 

                 DR. FASANO:  I have my candy so I can't

 

       leave you.

 

                 (General laughter.)

 

                 CHAIRMAN DURST:  Okay.  We will probably

 

       move on so we don't go too far into the lunch hour.

 

                 Our next speaker is Dr. Pekka Collin.  He

 

       is a professor at the University of Tampere Medical

 

       School in Finland.  He will discuss retrospective

 

       studies.

 

                          RETROSPECTIVE STUDIES

 

                 DR. COLLIN:  Yes, good morning everyone.

 

       I come from Tampere.  You probably know where

 

       Finland is and Tampere is a hundred miles north of

 

       our capitol, Helsinki.

                                                                162

 

                 (Slide.)

 

                 DR. COLLIN:  We at least in Tampere think

 

       that is the celiac center of Finland, but maybe

 

       somebody disagrees with that.  We have a half a

 

       million people around our hospital and now our

 

       clinical prevalence of celiac disease is

 

       approaching 1 percent.  I think it is .7 at the

 

       moment, so we have 1,000 patients with celiac

 

       disease.  Consequently, we have tried to examine

 

       both the symptoms and the diet.

 

                 (Slide.)

 

                 DR. COLLIN:  I had some specific issues

 

       which I should address at this meeting, and they

 

       are here.  I should explain why we carried out our

 

       retrospective analysis of the gluten content in our

 

       gluten-free products; then, also, calculate what is

 

       the significance of daily gluten exposure in this

 

       small amount of gluten; and then, also, to discuss

 

       is there some variability in the sensitivity of

 

       people with gluten intolerance which has been

 

       discussed here already many times.  That should

 

       also include patients who are taking with

                                                                163

 

       starch-based, gluten-free products and who are

 

       taking oats where we have a lot of experience.

 

                 (Slide.)

 

                 DR. COLLIN:  I think that celiac disease

 

       has been described very well by previous speakers,

 

       so I will go straight into the point.  However, I

 

       will emphasize that now we are talking about parts

 

       per million or 10 milligrams or 20 milligrams of

 

       gluten intake.

 

                 (Slide.)

 

                 DR. COLLIN:  In real life, if you have 100

 

       patients with celiac disease, I think 90 percent of

 

       them are taking 15 grams of gluten a day because

 

       they do not know that they have celiac disease.

 

                 Only 10 out of 100, for instance, in the

 

       U.S.A. I think know that they suffer from celiac

 

       disease.  Of the remainder 10, maybe 3 or 4 do not

 

       follow a gluten-free diet strictly because they

 

       don't care, or it is more likely because there are

 

       not enough products when they are eating out or

 

       eating in restaurants, and so on.

 

                 I think that is very important, that we

                                                                164

 

       have a good choice of products.  That is more

 

       important than some parts per million in order to

 

       achieve a good percentage of compliance.

 

                 The amount of threshold, I think it

 

       started more than 10 years ago in Europe.  The

 

       celiac societies were very, very active in these

 

       respects.  From southern countries, some people say

 

       that we are in northern countries poisoning our

 

       people because they know that we are giving them

 

       wheat-starch-based, gluten-free products.

 

                 On the other hand, our society, I think

 

       they are very -- I don't find the right word -- but

 

       I admire them because they said, "Please make the

 

       study.  Look at what we are now eating.  Celiac

 

       patients are the last who will have some extra,

 

       unnecessary dietary restrictions, so please make a

 

       study where you show whether we are now eating

 

       safely or not."  I think that was the background

 

       for our so-called "retrospective study."

 

                 At that time we were quite relaxed.  We

 

       were not afraid that we are poisoning our people,

 

       because we published a study where we showed that

                                                                165

 

       in our patients we did not have, in treating

 

       patients we did not have, any extra mortality and

 

       even we did not have any extra risk of malignant

 

       conditions at that time.

 

                 Then, we looked at what the Finnish

 

       celiacs are eating.  As expected, the majority of

 

       them took wheat-starch-based, gluten-free products.

 

                 (Slide.)

 

                 We can also see that compliance was very

 

       good.  These patients they were invited, after 5 or

 

       10 years on a gluten-free diet they were invited, a

 

       cohort of those patients, both so-called

 

       "sensitive" and not sensitive, and we can see that

 

       only a small percentage of patients had dietary

 

       transgressions.  Although there were a few who

 

       daily or twice a week or once a month had dietary

 

       lapses, most people preferred to follow a naturally

 

       gluten-free diet.

 

                 We also show that for these patients their

 

       quality of life is good, and they did not have any

 

       additional symptoms compared to the population.  As

 

       has been mentioned many times earlier, symptom is

                                                                166

 

       not a very reliable objective sign of gluten

 

       intolerance.

 

                 (Slide.)

 

                 DR. COLLIN:  This is an example how

 

       symptoms can be misleading.  This is maybe a little

 

       bit out of the topic, but I think this is very

 

       interesting.

 

                 We ask family doctors to send us all such

 

       patients who spontaneously reported that they get

 

       symptoms after taking wheat or rye.  The majority

 

       of them had also on their own account tried to

 

       avoid or withdraw these products from their diets,

 

       and they experienced clear improvement in symptoms.

 

                 We thought that many of them had latent or

 

       overt celiac disease, but to our surprise only 10

 

       percent of people with a clear history of

 

       intolerance to gluten had really celiac disease.

 

       Then, there are some which we thought that they

 

       maybe had wheat allergy.

 

                 When I was here yesterday I heard about

 

       that.  Yes, the diagnosis is so difficult, so I

 

       hope that I don't have to discuss this in more

                                                                167

 

       detail.

 

                 However, the majority of them, even with

 

       sophisticated methods, they did not have any signs

 

       of celiac disease and probably they have irritable

 

       bowel syndrome.  Hence, we cannot trust symptoms

 

       even in the diagnosis of celiac disease.

 

                 (Slide.)

 

                 DR. COLLIN:  Then, of course we have to go

 

       to small bowel biopsy as they did also earlier.  We

 

       took a control biopsy after 5 to 10 years from

 

       these patients who had been diagnosed with celiac

 

       disease and who were asked to come to our hospital.

 

                 (Slide.)

 

                 DR. COLLIN:  What we can see here is that

 

       this is the same villous height/crypt depth ratio

 

       which has been measured by, for instance,

 

       Alessio Fasano.  Here is our reference value for

 

       people who have no suspicion of celiac disease.

 

       They have come to endoscopy because of suspected

 

       some gastrointestinal disorder, reflux symptoms or

 

       dyspepsia.

 

                 We can see that in our long-term treated

                                                                168

 

       patients, there is a 95 confidence interval, so it

 

       was exactly the same as in our non-celiac people.

 

       I could show also a similar slide of

 

       intraepithelial lymphocytes, very similar.  They

 

       did not have extra intraepithelial lymphocytes.

 

                 We did not either have any so-called

 

       "highly sensitive" patients with celiac disease.

 

       We had some here who had not a complete recovery in

 

       the mucosa.

 

                 After dietary inspection, it turned out

 

       that all of these people are taking occasionally

 

       gluten.  Even once a month, I think that was in the

 

       data, the histological recovery was not complete

 

       Then, we had also here are the celiac patients

 

       where the ratio was of course low.

 

                 Then, we had some short-term treated

 

       patients, that means from half year to one year.

 

       We show that the healing was not complete at that

 

       time.  From this slide we had two questions.

 

                 First, when we have a complete recovery,

 

       are those patients still taking some small amounts

 

       of gluten or are their products complete

                                                                169

 

       gluten-free?

 

                 The second question was, When we have this

 

       incomplete recovery, does it depend on wheat starch

 

       or gluten contamination or is it normal life in

 

       celiac disease?  In other words, would the healing

 

       be better if instead of wheat starch used, the use

 

       of naturally gluten-free products?

 

                 To the first issue, Are those products

 

       contaminated which have shown that our people are

 

       doing well and their mucosal is healthy?  It was

 

       not surprising that most of naturally gluten-free

 

       products had less than 10 ppm gluten.

 

                 However, I think it is very important to

 

       realize that some of the so-called naturally

 

       gluten-free products, they may be contaminated with

 

       gluten, even quite high.  All of these were

 

       fulfilling the current European Codex standard.

 

                 If we go to the wheat-starch-based,

 

       gluten-free flours, there were two with zero

 

       gluten, and as expected most of them contained

 

       trace amounts of gluten.  Two had more than 100,

 

       but the majority has less than 100.  That was our

                                                                170

 

       idea that maybe we can set the limit to 100 ppm.

 

                 When I had this slide and my conclusion in

 

       Europe, one of the representatives of industry said

 

       that he was disappointed because I am talking about

 

       100 ppm, and I should have talked about the limit

 

       of 200 ppm because it is much easier for them.

 

                 However, I said that we had too few

 

       products here to assert that 200 ppm would be

 

       recommendable.  I think I will remind you that

 

       90 percent of our celiacs have used this product

 

       for 40 years or even more, and we have

 

       biopsy-proven results from that so-called challenge

 

       from 5 to 10 years.  The mucosal recovery, as I

 

       said, was perfect.

 

                 (Slide.)

 

                 DR. COLLIN:  We also looked at how much

 

       they did use those flours.  Maybe somebody who has

 

       taken gluten-free products can know that they are

 

       not necessarily as good as wheat, baking with

 

       wheat.

 

                 Nevertheless, here are how the patients

 

       used these products.  There was no difference

                                                                171

 

       between wheat-starch-based products or a naturally

 

       gluten-free diet.  The average was 80 grams, and

 

       the majority took less than 150 grams as you can

 

       see here.  There was no correlation between the

 

       villus damage and the amount of data used of loss.

 

                 (Slide.)

 

                 DR. COLLIN:  From here we come to this

 

       conclusion, which maybe you have seen this kind of

 

       table in Alessio Fasano's presentation.  Provided

 

       that we set the limit to 100 ppm, and provided that

 

       each of these products also contained the maximum

 

       amount allowed, when patients are taking 100 grams

 

       of those or 200 grams of those the gluten

 

       contamination is from 10 to 20 milligrams.

 

                 If you look at Fasano's results and if you

 

       look at some earlier, small studies -- even the

 

       Catassi study, which was referred to, and some

 

       smaller studies made by Sturgis and so on -- I

 

       think we are very, very safe here at the 100 ppm.

 

       I think also that our clinical experience will show

 

       that the same.

 

                 Of course, this is not a prospective

                                                                172

 

       study, and we did not have any control group, and,

 

       unfortunately, we did not have many patients who

 

       have clear dietary restrictions, so we cannot make

 

       any statistical analogies between those who are --

 

       what is the word -- cheating with their diet and

 

       who are not.  However, I think with this kind of

 

       system, we can treat our patients and have good

 

       compliance.

 

                 (Slide.)

 

                 DR. COLLIN:  If I can, go to the issue

 

       whether patients are more sensitive or

 

       hypersensitive patients with celiac disease.  When

 

       we look at those patients, we can see that their

 

       mucosal recovery takes place in a different way in

 

       different people.  That has been very well shown in

 

       some challenge studies.  Where earlier it was

 

       customary to accept diagnosis, we have once again

 

       to challenge the patients to gluten-free diets and

 

       look at if there will emerge new villus atrophy.

 

                 We show that in some cases it took two

 

       months or one month to see a mucosal relapse, but

 

       in some cases it took two or three years.  Our

                                                                173

 

       record is 15 years.  Fifteen years with normal diet

 

       and earlier diagnosed celiac disease, after 15

 

       years a mucosal relapse occurred.

 

                 Here we can see that in the short-term

 

       some people do not respond, and you could think

 

       that these might be so-called "hypersensitive."  If

 

       we give enough time and the patients are truly

 

       following the gluten-free diet, which means that we

 

       must be really accurate that they do not take wheat

 

       at the same time, I think in the long-term we have

 

       almost complete recovery.  We did not have any

 

       so-called "hypersensitive."

 

                 I think patients with refractory sprue

 

       they can be very sensitive because they do not

 

       respond at all to celiac disease, but that is a

 

       different issue.  It is probable that even zero

 

       gluten would not help them.  There is something

 

       wrong in their gut.  Probably the diagnosis has

 

       been made too late, and it does not recover any

 

       more.  I think that refractory sprue is outside of

 

       the topic of this day.

 

                 Also, we were discussing with Peter Chen,

                                                                174

 

       when he wrote to "Gastrointestinal Endoscopy" that

 

       complete mucosal recovery is not possible, and we

 

       had a very friendly, friendly discussion in the

 

       pages of that journal.  However, we said that it is

 

       possible when we have a good choice of products and

 

       people also outside the home know what celiac

 

       disease is what this means for the patient with a

 

       gluten-free diet.

 

                 The second issue in my slide was that

 

       could it be that the mucosal healing would be more

 

       rapid in those who are on a naturally gluten-free

 

       diet than in those who are maintaining

 

       wheat-starch-based, gluten-free products?

 

                 Here, we carried out a randomized

 

       prospective study of one year in newly detected

 

       celiac disease patients.  If we look at the villus

 

       healing here and here, villous height/crypt depth

 

       ratio, there were no differences between these two

 

       groups.  We can also see that in one year, you

 

       cannot achieve the limit of three, which is

 

       considered normal.

 

                 Similarly, when we look at intraepithelial

                                                                175

 

       lymphocytes, they decreased in a similar way in

 

       both patients.  At that time, unfortunately, we

 

       could not measure what was the exact amount of

 

       gluten these patients were taking; we did not have

 

       methods.  We can assume they took those same

 

       products which were mentioned in my last slide

 

       which contained trace amounts of gluten but not

 

       more than 100 ppm.

 

                 (Slide.)

 

                 DR. COLLIN:  If I may say some words about

 

       oats.  It was in Finland, the first publication.

 

       After that, very soon it was accepted for celiacs

 

       in Finland that they may use oats.  At the

 

       beginning we were very careful.  We followed up

 

       with them each month and looked at what to do, but

 

       now we do not do it anymore.

 

                 We made a question out, too.  We sent a

 

       question out to members of the Celiac Society, how

 

       do they appreciate oats.  As you can see, they like

 

       about the permission to eat oats.

 

                 Almost all said that it is a very

 

       significant part of every day gluten-free diet in

                                                                176

 

       terms of tasty and low lost.  They even thought

 

       that it is healthy, diversifies the diet, and we

 

       have a good availability in Finland of oat

 

       products.  I understand that maybe in some

 

       countries oat is not so important.

 

                 Some might say that in Finland they are

 

       not eating good, so maybe people in Italy do not

 

       operate yet in the same manner as in Finland, but

 

       we can discuss it.

 

                 (Slide.)

 

                 DR. COLLIN:  Here are how our people have

 

       now used oats, the majority of patients -- not

 

       great amounts, it is only 20 grams, 15 or 20 grams.

 

       There, most of the studies are about approximately

 

       50 grams, so less than in those randomized studies.

 

                 Some people do not prefer oats, and that

 

       is the same thing in people in general not only in

 

       celiac patients.  Some of them had stopped, and the

 

       reason is that they had developed symptoms.  Some

 

       even got a rash, basically dermatitis

 

       herpetiformis.  We do not have any proof that the

 

       reason for stopping would be that they

                                                                177

 

       simultaneously had mucosal damage.  Usually, the

 

       mucosa is good even though the patient has stopped

 

       the diet.

 

                 The rest, in dermatitis herpetiformis, we

 

       also saw that even in patients with no oat diet, so

 

       even they may have a temporary rash.  There are

 

       some clinical relapses in patients with dermatitis

 

       herpetiformis also.

 

                 It is excellent to study these questions,

 

       because we can change the subjective symptoms quite

 

       rapidly to objective science, count the number of

 

       blisters, for instance.

 

                 (Slide.)

 

                 DR. COLLIN:  We also looked at the quality

 

       of life in patients with oats.  Actually, there was

 

       no change, difference, compared to patients with no

 

       oats.  This also was a prospective, randomized

 

       study in treating celiac disease.

 

                 Interestingly, those patients who were

 

       taking oats, they reported more symptoms of

 

       diarrhea, which was statistically significant.

 

       They also reported more constipation, which was not

                                                                178

 

       significant.  Even in these patients, we did not

 

       have any mucosal deterioration.

 

                 From this we learned that if we start on a

 

       gluten-free diet with oats, we must inform the

 

       patient that "You may have symptoms after this.  If

 

       you have symptoms, why continue.  But it is

 

       improbable that we have done any harm to your

 

       small-bowel mucosa.

 

                 We also saw that those who were taking

 

       oats had a little bit more intraepithelial

 

       lymphocytes, not CD3 lymphocytes, which we have

 

       discussed today, but gamma/delta lymphocytes.

 

                 The gamma/delta lymphocytes were a little

 

       bit increased in the oat group.  I cannot explain

 

       the reason for that, and that has not been

 

       published elsewhere -- but that is the fact.

 

                 (Slide.)

 

                 DR. COLLIN:  Here are my conclusions to

 

       the questions which I was asked to answer.  Maybe I

 

       also specific questions which you have, specific

 

       issues which you have to address in the final

 

       report.

                                                                179

 

                 If I may say something about the

 

       subpopulation, the most highly sensitive people, I

 

       think such people of course may be, but eventually

 

       they have good mucosal recovery, provided that they

 

       follow a gluten-free diet.  The majority of these

 

       highly sensitive patients are probably such people

 

       who have advertent or inadvertent gluten intake.

 

                 We can also remember that even if it

 

       happens, the consequences are not disastrous,

 

       because they do not develop an anaphylaxis aspect

 

       as do people with peanut allergy as we heard today.

 

                 We can quite easily detect these highly

 

       sensitive, if we after the diagnosis, one year

 

       after the diagnosis, take a small-bowel biopsy and

 

       look at whether there is an improvement in the

 

       mucosal architecture.  If there is not, we must

 

       consider that they may be very sensitive, but

 

       usually they do not follow the gluten-free diet.

 

                 About the risk of malignant diseases, I

 

       think the whole literature tells that those people

 

       who are at an increase risk of malignant lymphoma,

 

       their diagnosis has been made too late.  They

                                                                180

 

       already have lymphoma when the symptoms of celiac

 

       disease appear and when they get the diagnosis of

 

       celiac disease, or they have had dietary

 

       transgressions for a prolonged time.

 

                 Of over 1,000 patients I have seen during

 

       the 15 years, I have seen one patient who has

 

       developed lymphoma after being 5 or 10 years on an

 

       apparently gluten-free diet.  The risk of these

 

       severe complications in those small daily intake is

 

       probably very low.  Even our new data show the

 

       same, which is now published only in abstract.

 

                 Similarly, the mortality, it depends on

 

       those patients who come to the hospital together

 

       with the diagnosis of celiac disease and later,

 

       usually within six months, we can see that they

 

       also have lymphoma.

 

                 (Slide.)

 

                 DR. COLLIN:  What about the oats?  Here I

 

       summarized some studies.  Those with plus signs

 

       they are those who have shown that oats have no

 

       adverse effect on the mucosa.  I think nearly

 

       almost all of these studies are randomized,

                                                                181

 

       open-randomized.  They have a control group with

 

       non-oat.  We have hundred of patients who seem to

 

       tolerate oats.

 

                 But I think I would be stupid if I did not

 

       see also those two papers and patients who are

 

       sensitive.  I cannot close my eyes from the

 

       results, because Don Kasarda told the data very

 

       convincingly.

 

                 I don't know who they are.  Maybe there

 

       are some who really develop villus atrophy after

 

       taking oats, but that must be an extremely rare

 

       condition.  Because, as you see, we have so many,

 

       many patients who are taking oats, and we have not

 

       seen this phenomenon.

 

                 Still, we must be careful, and we must be

 

       careful because patients with oats may develop

 

       symptoms.  If everything does not go well, of

 

       course we stop the use of oats.  However, we must

 

       be aware of that, that maybe there are some rare

 

       patients where it acts the same as gliadin for most

 

       people with celiac disease.

 

                 I don't know whether these, my results and

                                                                182

 

       recommendations, can be applied in the United

 

       States but that is how we are doing now.  Our

 

       celiac society is very happy because we said that

 

       you can continue with starch-based, gluten-free

 

       products.

 

                 Thank you very much.

 

                 CHAIRMAN DURST:  Thank you.

 

                       QUESTION AND ANSWER SESSION

 

                 CHAIRMAN DURST:  Do we have questions?

 

                 Suzanne.

 

                 DR. TEUBER:  Suzanne Teuber.  My question

 

       relates to the applicability of the diet parameters

 

       to the United States dealing with how much

 

       gluten-free flour do people in different parts of

 

       the world ingest, if they were to have the option

 

       of knowing that something was truly, truly

 

       gluten-free.

 

                 You talk about 100 parts per million.  It

 

       was your data that came up with the 80 grams a day

 

       that people ingest.  I'm wondering -- you know, we

 

       are not setting any level here today -- in terms of

 

       United States' folks, I have no idea how that would

                                                                183

 

       apply.  Would this be a safe level for them?  Or,

 

       here, would people be preferring to adjust much

 

       more?  Do you have any input on that?

 

                 DR. COLLIN:  I think there is not much

 

       data on that, how much people really in different

 

       parts of the world are really using wheat or other

 

       flours which may be harmful to patients with celiac

 

       disease.

 

                 I think that this is a subject for further

 

       studies.  Maybe somebody here knows how much celiac

 

       patients are here using gluten-free flours, but I

 

       don't know.  I have not seen any publications about

 

       this issue.

 

                 CHAIRMAN DURST:  Any other questions?

 

                 DR. McBRIDE:  Margaret McBride.  Did I

 

       understand correctly that gluten-free in Finland

 

       means 100 part per million?

 

                 I guess for me, as I'm thinking about it,

 

       maybe part of the difference between the two

 

       studies, aside from the obvious

 

       retrospective/prospective, et cetera, is that in

 

       Italy the gluten-free diet did contain some,

                                                                184

 

       although very little at 20 parts per million

 

       gluten, in addition to what was administered.

 

                 I don't know if there is an estimation of

 

       how much that would be.  I'm also thinking maybe

 

       there is more interest in pasta in Southern Europe

 

       than in Northern Europe.

 

                 DR. COLLIN:  I think that today we have

 

       given the formal Codex standard which says that

 

       200 ppm is okay, but of course we need to

 

       reconsider that.

 

                 I think that in the whole of Europe there

 

       will be two limits, that is the 20 milligram which

 

       can be used in the highly sensitive people, but in

 

       the majority of people it is 100 ppm.

 

                 Of course, there is a problem with

 

       labeling, how we should label that.  We cannot say

 

       that it is "low gluten," because then people will

 

       use that.  That is our problem.

 

                 What our recommendation is, is that maybe

 

       the majority of people with celiac disease can

 

       tolerate products which are under the limit of

 

       100 ppm.

                                                                185

 

                 DR. KELLY:  Ciaran Kelly.  I wonder in

 

       terms of compliance with the diet and acceptance of

 

       the diet, is there a big difference between 20

 

       parts per million or 100 parts per million from the

 

       perspective of the palatability of the food?

 

                 DR. COLLIN:  I think the important thing

 

       is, at least the industry in Europe says, that, if

 

       we go to very low level, there are not so many

 

       alternatives for gluten-free products, which again

 

       may result in that general compliance will be worse

 

       than I have shown now.

 

                 How the products, how they--?  I think

 

       that those wheat-starch products, I think they are

 

       very tasteful.  Does it depend on the small

 

       milligrams of gluten or not?  I don't know.  But,

 

       as can be seen, most of the people are preferring

 

       those products instead of naturally gluten-free.

 

                 CHAIRMAN DURST:  Anyone else?

 

                 (No verbal response.)

 

                 CHAIRMAN DURST:  If not, thank you,

 

       Dr. Collin.

 

                 Our final speaker for this morning is

                                                                186

 

       Rhonda R. Kane from the Consumer Safety Office of

 

       CFSAN, FDA, on international perspectives on

 

       gluten-free.

 

                INTERNATIONAL PERSPECTIVES ON GLUTEN-FREE

 

                 MS. KANE:  Good afternoon.  My name is

 

       Rhonda Kane.  I am with the Food and Drug

 

       Administration, and I was asked to present

 

       information to the Food Advisory Committee about

 

       how the term "gluten-free" is defined in other

 

       countries and the basis for those definitions.

 

                 (Slide.)

 

                 MS. KANE:  My presentation today will

 

       focus on four examples of international or national

 

       definitions of the term "gluten-free" that apply to

 

       labeled packaged foods.

 

                 The first two examples I will be

 

       discussing pertain to Codex Alimentarius and they

 

       include, the first one, Codex Standard 118-1981,

 

       which pertains to the Codex standard for

 

       gluten-free foods that was established in 1981, was

 

       amended in 1983 and is in effect today; and, two,

 

       the Proposed Draft Revised Standard for Gluten-Free

                                                                187

 

       Foods at Step 7 that is now under consideration by

 

       the Codex Committee on Nutrition and Foods for

 

       Special Dietary Uses as a replacement for the

 

       current standard.

 

                 For ease in my presentation, I am going to

 

       refer the Codex Committee on Nutrition and Foods

 

       for Special Dietary Uses simply as the "Codex

 

       Nutrition Committee."

 

                 In the early 1990s, members of the Codex

 

       Nutrition Committee agreed that developments in the

 

       characterization of gluten on studies on gluten

 

       tolerance warranted a revisiting of the current

 

       standard and an updating of it.

 

                 The current proposed standard has

 

       undergone several revisions and is now at Step 7 of

 

       an 8-step process pending resolution of certain

 

       issues including what method of detection is going

 

       to be used for gluten and the results of gluten

 

       threshold studies in celiac patients.  The Codex

 

       Nutrition Committee will be meeting in November

 

       2005, and will be discussing the proposed standard.

 

                 The third example of gluten-free that I

                                                                188

 

       will be discussing is found in Canada's Food and

 

       Drug Regulations at Section B.24.018.  It became

 

       effective on May 1, 1996.

 

                 Lastly, I will review the definitions of

 

       both "gluten-free" and "low-gluten" that are found

 

       in Clause 16 of Standard 1.2.8 of the Australia

 

       New Zealand Food Standards Code, and I will also

 

       discuss the definition of gluten found in Clause 1

 

       of that same standard.

 

                 (Slide.)

 

                 MS. KANE:  The current Codex standard that

 

       is in effect today defines "gluten" as "Those

 

       proteins commonly found in wheat, triticale, rye,

 

       barley or oats to which some persons are

 

       intolerant."

 

                 The current standard further defined the

 

       term "gluten-free" to mean that "The total nitrogen

 

       content of gluten-containing cereal grains used in

 

       the product does not exceed 0.5 gram nitrogen per

 

       100 grams of the cereal grains on a dry weight

 

       basis."

 

                 (Slide.)

                                                                189

 

                 MS. KANE:  The current standard states

 

       that it does not apply to foods which in their

 

       normal form do not contain gluten.  Gluten-free

 

       foods are defined according to two categories,

 

       those that contain the cereal ingredients -- wheat,

 

       triticale, rye, barley or oats or their

 

       constituents, which have been rendered gluten-free

 

       -- or those foods in which any ingredients normally

 

       present that contain gluten have been substituted

 

       by other ingredients that do not contain gluten.

 

                 (Slide.)

 

                 MS. KANE:  In comparison, the Codex

 

       Proposed Draft Revised Standard for Gluten-Free

 

       Foods at Step 7 defines "gluten" to be "The protein

 

       fraction from wheat, rye, barley oats or their

 

       crossbred varieties and derivatives to which some

 

       persons are intolerant and that is insoluble in

 

       water and 0.5 molar solution of sodium chloride."

 

                 You will see that in this definition and

 

       in others that are occurring in the proposed

 

       standard information within brackets is intended to

 

       indicate that that information is pending

                                                                190

 

       additional discussion at the Codex Nutrition

 

       Committee.  Their next session meets in November

 

       2005.

 

                 The Proposed Standard also defines the

 

       term "Prolamin" to mean "The fraction from gluten

 

       that can be extracted by 40 to 70 percent aqueous

 

       ethanol."  This definition specifically identifies

 

       the prolamins: gliadin from wheat, secalin from

 

       rye, hordein from barley, and avenin from oats.

 

                 (Slide.)

 

                 MS. KANE:  The Proposed Standard also

 

       states that it applies to those foodstuffs and

 

       ingredients which have been especially processed or

 

       prepared to meet the dietary needs of persons

 

       intolerant to gluten.

 

                 Therefore, this parameter is similar to

 

       the one for the current standard in that neither of

 

       the two standards, the current and the proposed,

 

       would include foods that are naturally or

 

       inherently free of gluten.

 

                 The proposed standard also identifies

 

       three categories of gluten-free foods where their

                                                                191

 

       definitions specify certain limits on their gluten

 

       content.

 

                 (Slide.)

 

                 MS. KANE:  In the first proposed category,

 

       gluten-free foods consisting of ingredients which

 

       do not contain any prolamins from wheat or all

 

       Triticum species -- rye, barley, oats -- or their

 

       crossbred varieties cannot have a gluten level that

 

       exceeds 20 parts per million.  Again, you will see

 

       that "20 parts per million" is within brackets,

 

       therefore, this number is pending.

 

                 (Slide.)

 

                 MS. KANE:  This proposed definition also

 

       specifically cites three examples of grains within

 

       different species of Triticum, they are: spelt,

 

       kamut, and durum wheat.

 

                 Although triticale is not one of the

 

       grains that is identified within the definition by

 

       its name, it is included because it is a crossbred

 

       hybrid of wheat and rye.

 

                 In the second proposed category of

 

       gluten-free foods, they are those consisting of

                                                                192

 

       ingredients from wheat, rye, barley, oats, spelt or

 

       their crossbred varieties that have been rendered

 

       gluten-free and cannot have a gluten level that

 

       exceeds 200 parts per million.  Again, "200 parts

 

       per million" is cited in brackets, and it is

 

       therefore pending.

 

                 (Slide.)

 

                 MS. KANE:  In the third proposed category,

 

       gluten-free foods consisting of any mixture of the

 

       ingredients as described in the previous two

 

       categories, cannot have a gluten level that exceeds

 

       200 parts per million.  Again, "200 parts per

 

       million" is cited in brackets and it is pending.

 

                 (Slide.)

 

                 MS. KANE:  Based upon my reading of the

 

       session reports for the Codex Nutrition Committee

 

       and related documents, it appears that the

 

       rationale for including two levels, the 20 and 200

 

       parts per million, in the definition of gluten-free

 

       foods was to accommodate different points of view

 

       of the Codex member countries that thought there

 

       should be a different level of gluten based upon

                                                                193

 

       their experience with their populations, what would

 

       be adequately protective.

 

                 There were some countries that believed

 

       either the lowest limits of detection or 20 parts

 

       per million would be most protective of those that

 

       are very sensitive to gluten.

 

                 Twenty parts per million was considered a

 

       practical limit to make it more feasible for

 

       industry to produce gluten-free foods in that

 

       category.

 

                 Other countries believed that the higher

 

       level of 200 parts per million would be

 

       appropriate, because they had experiences with

 

       citizens in their country that had celiac disease

 

       where they had been consuming wheat-starch-based

 

       products for years without harm, and they enjoyed

 

       them.

 

                 The 20 parts per million level would

 

       essentially prohibit the inclusion of those

 

       wheat-starch-based products.  Therefore, it was a

 

       compromise, the low limit and the high limit, and

 

       they realized they could create some confusion on

                                                                194

 

       the part of the consumer.

 

                 I also want to point out that the proposed

 

       definition of gluten-free foods specifically cites

 

       that whatever detection method is used it should

 

       have a detection limit of at least 10 parts per

 

       million gluten in the product on a dry weight

 

       basis.

 

                 (Slide.)

 

                 MS. KANE:  The next definition I will

 

       discuss is that found in Canada's Food and Drug

 

       Regulations at Section B.24.018, and it states:

 

       "No person shall label, package, sell or advertise

 

       a food in a manner likely to create an impression

 

       that is a gluten-free food unless the food does not

 

       contain wheat, including spelt and kamut, or oats,

 

       barley, rye, triticale or any part thereof."

 

                 (Slide.)

 

                 MS. KANE:  Canada's definition of

 

       gluten-free prohibits the use of derivatives or

 

       constituents of any of the cited grains.

 

       Therefore, wheat starch would not be allowed in a

 

       product that was labeled gluten-free.

                                                                195

 

                 It is my understanding based upon

 

       communication with staff who work with Health

 

       Canada and the Canadian Food Inspection Agency,

 

       that the definition that Canada is using was

 

       developed using a rule-making process, but they

 

       closely coordinated with the Canadian Celiac

 

       Association in the parameters for this definition.

 

                 Canada underwent a rule-making process

 

       similar to the one that we use in the United States

 

       where they reviewed the relevant scientific

 

       literature, they published a proposed rule,

 

       considered comments before it went final, and they

 

       determined that back in the mid-1990s that there

 

       was insignificant or insufficient I should say

 

       scientific evidence to support establishing a level

 

       that would be safe for all celiac patients.

 

                 (Slide.)

 

                 MS. KANE:  In the last definitions of

 

       gluten-free that I will be discussing, in the

 

       Australia New Zealand Food Standards Code, first,

 

       in Clause 1 of Standard 1.2.8 of the "Code," which

 

       I will refer to simply as that rather than

                                                                196

 

       repeating that long name, it defines "gluten" as

 

       "'The main protein in wheat, oats, barley,

 

       triticale and spelt relevant to the medical

 

       conditions, Coealic disease and dermatitis

 

       herpetiformis.'"

 

                 It also defines in Clause 16 of that same

 

       standard the terms "gluten-free" and "low gluten."

 

                 (Slide.)

 

                 MS. KANE:  "Gluten-free" is defined as

 

       those foods that contain no detectable amount of

 

       gluten.  They also cannot contain any oats or their

 

       products or any cereals containing gluten that had

 

       been malted or their products.  It has to meet all

 

       of those three criteria not just one.

 

                 In addition, their Code defines the term

 

       "low-gluten foods" to mean those that contain no

 

       more than 20 milligrams of gluten per 100 grams of

 

       food.  Now, although not stated in the Code as

 

       such, this level of gluten is equivalent to 200

 

       parts per million.

 

                 (Slide.)

 

                 MS. KANE:  It is my understanding based

                                                                197

 

       upon communication with Food Standards Australia

 

       New Zealand's staff that they also underwent a

 

       rule-making process where they proposed these

 

       definitions for "gluten-free" and "low-gluten"

 

       before they went final.

 

                 They did a review of the relevant

 

       scientific literature.  They considered public

 

       comment, and they also consulted with experts in

 

       the appropriate fields to develop the definitions

 

       that are in effect today.

 

                 In addition, the fair trading laws in both

 

       Australia and New Zealand were interpreted as

 

       prohibiting the term "gluten-free" from being used

 

       with any foods that contained any detectible amount

 

       of gluten.

 

                 (Slide.)

 

                 MS. KANE:  Further, the definition of

 

       gluten-free was influenced by a lack of reliable

 

       analytical methods to detect gluten in oats and

 

       malted cereals.  Essentially, their definition says

 

       not only no detectible amount of gluten, but no

 

       oats or other products, no malted cereals

                                                                198

 

       containing gluten and their products because of

 

       this limitation of analytical methods.

 

                 (Slide.)

 

                 MS. KANE:  The Code includes two

 

       definitions, "gluten-free" and "low gluten," to

 

       provide citizens who have celiac disease a choice

 

       between which level of gluten-containing foods they

 

       want to consume based upon their individual gluten

 

       tolerance level and the advice of their healthcare

 

       provider.

 

                 In closing, I would like to sincerely

 

       thank the staff that I consulted with at Health

 

       Canada, and the Canadian Food Inspection Agency, as

 

       well as Food Standards Australia and New Zealand.

 

                 With that, I will take any questions.

 

                 CHAIRMAN DURST:  Thank you very much.

 

                       QUESTION AND ANSWER SESSION

 

                 CHAIRMAN DURST:  Does the Committee have a

 

       question or comment?

 

                 Erica.

 

                 DR. BRITTAIN:  Erica Brittain.  I guess I

 

       find it appealing the idea of the two levels, just

                                                                199

 

       as a comment, in the last one you cited.  This

 

       might be applicable to the allergy situation as

 

       well.

 

                 CHAIRMAN DURST:  Okay.  Anything else?

 

                 Mark.

 

                 DR. NELSON:  Mark Nelson.  Did your

 

       contacts in Australia, New Zealand and Canada give

 

       any indication that they might change their

 

       definitions or their categorizations if there were

 

       more work done on thresholds, if that data based

 

       changed?

 

                 MS. KANE:  That sort of conversation

 

       didn't occur between me and them, but I would think

 

       because they are government agencies, just like FDA

 

       is, if there were newer information on the horizon,

 

       they would probably consider it.  Whether they

 

       would go through the rule-making process and change

 

       it, I guess they would base it on the needs of

 

       their own populations.

 

                 DR. NELSON:  I guess the opportunity for

 

       -- this is Mark Nelson again -- two categories does

 

       have some attractiveness.  I guess at Codex it is

                                                                200

 

       going to be gluten-free and really gluten-free.

 

                 (General laughter.)

 

                 CHAIRMAN DURST:  Suzanne.

 

                 DR. TEUBER:  Suzanne Teuber.  To your

 

       knowledge in talking with these folks, have their

 

       been any consumer-preference studies or behavior

 

       studies completed or underway with how the celiac

 

       disease patient is using these standards in terms

 

       of their overall intake?

 

                 MS. KANE:  I don't have personal knowledge

 

       of that.  However, the Canadian Celiac Association

 

       is very supportive of Canada's definition of

 

       gluten-free.  Because they were instrumental in

 

       helping develop it, so they were very supportive of

 

       it.

 

                 CHAIRMAN DURST:  Yes.

 

                 DR. McBRIDE:  Margaret McBride.  Do I

 

       understand from your slides about the Codex

 

       proposed changes that the term "gluten-free" would

 

       be applied both to those foods that contained none

 

       of the products in question and are lower than 20

 

       parts per million, and to those foods that are

                                                                201

 

       wheat-based and gluten has been removed but would

 

       contain up to 200 parts per million?  I realize the

 

       numbers are in question.

 

                 MS. KANE:  Right.  They do not apply to

 

       the term.  They don't want the term "gluten-free"

 

       to apply to naturally gluten-free foods but those

 

       that have been specially processed or prepared

 

       where the formulation has been controlled.

 

                 There is a substitution of ingredients or

 

       a removal of gluten from ingredients.  It would

 

       cover categories that are wheat-starch-based.  That

 

       is where the 200 parts per million definition is

 

       coming into play.

 

                 Member countries did not want

 

       wheat-starch-based products to be excluded from

 

       being called gluten-free, if there was only one

 

       definition of 20 parts per million.  That is why

 

       they compromised and had the two levels that would

 

       apply.

 

                 DR. McBRIDE:  A follow-up.  Would I assume

 

       that they would then be called something different,

 

       or would we be expecting the consumer --

                                                                202

 

                 (Simultaneous discussion.)

 

                 MS. KANE:  No.  Right now, as it stands,

 

       they are saying one definition "gluten-free" to

 

       apply to three categories of gluten-free.  However,

 

       that could change.

 

                                Now, keep in mind all of this

 

       is pending.  It is at Step 7 of an 8-step process.

 

       I know there is a Working Group, the Prolamin

 

       Analysis and Toxicity Group.  That information will

 

       come into play.  These levels are not definite and

 

       they could change.

 

                 If both of those situations or all three

 

       were called gluten-free, then we would have to

 

       expect that the consumer who felt that they were

 

       very sensitive and wanted truly a very low level,

 

       below 20 parts per million, would have to read and

 

       understand the names for the various grains,

 

       et cetera, that would be on the ones where in fact

 

       products that at least one time had contained

 

       gluten were used.

 

                 I understand that, and the report I cited

 

       on my second slide, the "ALINORM Report" is the

                                                                203

 

       latest one, to my knowledge, that contains the

 

       language of the current proposed standard at

 

       Step 7.  It doesn't go into those details about how

 

       it might be labeled alternatively or what

 

       additional information it would include.  You're

 

       right, it does create confusion.  How would you

 

       know if it is 20 parts?  How would you know if it

 

       is 200 parts?

 

                 That issue was brought up in some related

 

       documents, but it is not found in the latest

 

       session report.  However, you're absolutely right.

 

                 DR. NELSON:  This is Mark Nelson.  I just

 

       want to address that question about the Codex

 

       label.  There is a separate committee, Codex

 

       Committee on Food Labeling, and these definitions I

 

       would expect would ultimately be referred to the

 

       Codex Committee on Labeling to address the issue

 

       you have just raised about the potential confusion.

 

                 CHAIRMAN DURST:  Suzanne.

 

                 DR. TEUBER:  Suzanne Teuber.  I also see

 

       an issue about cross-contamination problems with

 

       foods that you wouldn't expect to contain gluten

                                                                204

 

       and yet might contain contaminants because some of

 

       these, the rules that you are talking about, really

 

       don't address that.

 

                 Do you have any information on that, like

 

       say, corn that may be processed in a place that

 

       also has processed wheat?  It really would be

 

       beneficial to the consumer if it were to undergo

 

       testing and have a specific label, and yet these

 

       other definitions in other countries don't seem to

 

       cover that all.  It would probably just come out

 

       with no statement.  Is that a correct

 

       interpretation?

 

                 Or, actually maybe, Dr. Nelson--?

 

                 DR. NELSON:  I think in Europe and Codex

 

       also has a standard for good manufacturing

 

       practices; the Europeans have the equivalent.  I

 

       think the issue there would be the responsibility

 

       of the manufacturer to maintain good manufacturing

 

       practices and prevent as much possible that cross

 

       contact.

 

                 CHAIRMAN DURST:  Marc.

 

                 DR. SILVERSTEIN:  Marc Silverstein.  Would

                                                                205

 

       you clarify the categories of foods to which this

 

       would apply?  I would like you to, because I'm not

 

       sure I understood the criteria exactly.  If a food

 

       has multiple ingredients, does this apply to all of

 

       the ingredients in the food?

 

                 This is packaged and labeled food.  One or

 

       the major ingredient may be a food which in its

 

       normal form does not contain gluten, yet there

 

       might be other ingredients perhaps mixed in with it

 

       that would.

 

                 Would it be that it applies to a labeled

 

       package food which any of the ingredients contain

 

       gluten, or would it be just the major ingredient

 

       does not contain gluten and there might be some

 

       additive or some other component ingredient?

 

                 MS. KANE:  It is my understanding it would

 

       apply to all ingredients.  It would be selectively.

 

       If a packaged food that is labeled gluten-free, it

 

       would have to conform to the proposed.  Of course,

 

       again, it is proposed so it is not a done deal.

 

       However, there are categories going back.

 

                 Can we go back?  Can you reverse it back. 

                                                                206

 

       It is probably more towards the front.  Okay, that

 

       one right there.

 

                 (Slide.)

 

                 MS. KANE:  That is the first category

 

       consisting of ingredients.  It doesn't say primary

 

       ingredients.  It means ingredients.  That is how I

 

       understand it.  Keep in mind I've never been a

 

       member of the U.S. delegation to a Codex Committee

 

       meeting.  I do not have firsthand knowledge of the

 

       discussions.  It is only based on my reading of

 

       their session reports and related documents.  The

 

       way that is written I would interpret that to mean

 

       all ingredients.  Maybe someone who has attended

 

       the Codex could speak to that?

 

                 CHAIRMAN DURST:  Mark.

 

                 DR. NELSON:  Mark Nelson.  I think

 

       everybody would interpret that as all ingredients

 

       not just the main ingredients but including the

 

       minor ingredients, flavors, spices, and so on.

 

                 I can just talk a little bit about my

 

       experience in the food industry.  I have worked

 

       both for packaged goods companies but also

                                                                207

 

       suppliers to packaged goods companies.

 

                 They look at it very carefully to find out

 

       what the subingredients might be in, say, flavors

 

       or an additive or carriers or something like that.

 

       I can assure you, being a supplier to companies

 

       like Nestle or Kellogg's or Kraft, we have to

 

       provide a fairly substantial dossier to them for

 

       every ingredient we supply them to deal with issues

 

       like allergens and gluten levels as well.  The food

 

       industry itself does take this very seriously.

 

                 CHAIRMAN DURST:  Soheila.

 

                 DR. MALEKI:  Soheila Maleki.  I guess this

 

       is more a question.  It seems to me that based on

 

       what we have seen on some of the slides you've

 

       shown today that there really isn't good analytical

 

       method to be able to determine.

 

                 For example, the nitrogen content, you

 

       could measure every protein in there and you could

 

       weigh overestimate the amount of gluten.  Measuring

 

       gluten in the insoluble water fraction, that seems

 

       to be, again, if you can solubilize it.  If you

 

       can't really detect it, okay.

                                                                208

 

                 DR. NELSON:  I'm sorry, you may have to

 

       start over.  Sorry about that.

 

                 (General laughter.)

 

                 DR. MALEKI:  It is kind of a question.

 

       Based on this, I don't think there is really an

 

       analytical method that can make you comply to this,

 

       so how does this work?  How are they going to

 

       enforce it?

 

                 MS. KANE:  Keep in mind that the nitrogen

 

       definition of gluten is the current one.  They are

 

       proposing it be defined as the protein fraction for

 

       wheat, rye, barley, et cetera, to which persons are

 

       intolerant and it is insoluble in water and a

 

       0.5 molar solution to sodium chloride.

 

                 However, there is an analytical method

 

       component of a standard, and that is pending

 

       because they were talking about the R5 Mendez

 

       method, ELISA.  They knew that they would have to

 

       have a method that was sensitive enough, reliable,

 

       accurate and would detect the types of proteins

 

       that they are talking about in their definition.

 

                 That is going to be, I'm assuming, part of

                                                                209

 

       the discussion at the next Codex meeting is to

 

       bring that information about the methodology into

 

       play, because those were the two components, the

 

       methodology and threshold levels.  Those are the

 

       two areas needed to be worked out, and so I think

 

       that is going to be the crux of the discussion at

 

       the next Codex meeting.

 

                 DR. MALEKI:  I just wanted to make a

 

       comment as a follow-up.

 

                 CHAIRMAN DURST:  Oh, okay.

 

                 DR. MALEKI:  I'm Soheila Maleki.  It seems

 

       like the antibodies, the R5 kit again doesn't

 

       detect gluten it detects gliadin.  Maybe Steve can

 

       help with that somewhere along the line.

 

                 All right, go ahead.

 

                 DR. CALLERY:  Pat Callery.  If the

 

       analytical part can be worked out, which I think it

 

       can.  I wonder if there is an analogy here with

 

       caffeine where we have caffeine-free sodas and

 

       such, which we expect to have no caffeine, and

 

       coffee that is decaffeinated that does have

 

       caffeine in it.  The word is not very pretty,

                                                                210

 

       "deglutinated."

 

                 There may be an analogy that says when it

 

       is gluten-free it is truly gluten-free and when it